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OKLAHOMA STATE MEDICAL ASSOCIATION

HEALTH SCIENCES LIBRARY

UNIVERSITY OF M^RY* AMD

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Predominant

psychoneurotic

anxiety

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depressive

symptoms

Before prescribing, please consult com-
plete product information, a summary of
which follows:

Indications: Tension and anxiety states;
somatic complaints which are concomi-
tants of emotional factors; psychoneurotic
states manifested by tension, anxiety, ap-
prehension, fatigue, depressive symptoms
or agitation; symptomatic relief of acute
agitation, tremor, delirium tremens and
hallucinosis due to acute alcohol with-
drawal; adjunctively in skeletal muscle
spasm due to reflex spasm to local pathol-
ogy, spasticity caused by upper motor

neuron disorders, athetosis, stiff-man syn-
drome, convulsive disorders (not for sole
therapy).

Contraindicated: Known hypersensitivity
to the drug. Children under 6 months of
age. Acute narrow angle glaucoma; may
be used in patients with open angle glau-
coma who are receiving appropriate
therapy.

Warnings: Not of value in psychotic pa-
tients. Caution against hazardous occupa-
tions requiring complete mental alertness.
When used adjunctively in convulsive dis-

orders, possibility of increase in frequer
and/or severity of grand mal seizures rr
require increased dosage of standard ar
convulsant medication; abrupt withdrav
may be associated with temporary in-
crease in frequency and/or severity of
seizures. Advise against simultaneous i
gestion of alcohol and other CNS depre:
sants. Withdrawal symptoms (similar tc
those with barbiturates and alcohol) ha
occurred following abrupt discontinuar
(convulsions, tremor, abdominal and rr
cle cramps, vomiting and sweating). Ke
addiction-prone individuals under caret

^2 6 fa

JANUARY

1975

Vol. 68, No. 1

of th e Oklah oma State M edi cal As so ciati on

EDITORIAL BOARD

MARK R. JOHNSON, MD
Editor-in-Chief

HARRIS D. RILEY, Jr., MD
Editor

ROBERT G TOMPKINS, MD
Editor

ERNEST LACHMAN, MD
Corresponding Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

OFFICERS

JACK L. RICHARDSON, MD
President

ROGER J. REID, MD
Vice-Resident

HAVEN W. MANKIN, MD
Secretary-Treasurer

STAFF

DON BLAIR
BusinessManager

LOUISE MARTIN
EditorialAssistant

THE JOURNAL is the official publica-
tion of the Oklahoma State Medical Associa-
tion, and is published monthly under the di-
rection of the Board of Trustees, 601 N.W.
Expressway, Oklahoma City, Okla. 73118.
Publication office (printer) 222 East Eufaula
St., Norman, Okla. 73069. Second-class
postage paid at Oklahoma City, Okla-
homa 73125.

SUBSCRIPnON TO THE JOURNAL is included in
membership fees. Other subscriptions are
$6.50 per year or $1.00 per copy with each
request subject to approval of the Editorial
Board.

POSTMASTERS: Send all change of address
notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

CONTENTS

editorial

On Stuffing Crows ....... 1

President’s Page ........ 2

scientific

Civilian Vascular Injuries: A Clinical Review, Thomas
A. Marberry, James M. Hartsuck, MD and G.

Rainey Williams, MD ...... 3

Towards Control of Breast Cancer In Oklahoma,
Arthur F. Hoge, MD and G. Bennett Humphrey ,

MD, PhD 8

Laboratory Practices In Mycobacteriology : Results Of
A Survey Of Oklahoma Laboratories, Dixie E.

Snider, Jr., MD and R. LeRoy Carpenter, MD,

MPH 13

News From the Oklahoma State Department of

Health 18

news

Dues and Finances Dominate AMA House of Dele-

gates Meeting ....... 19

Washington Political Profile for 1975 ... 20

Ford Announces Administration’s Health Insurance

Plan 22

Tulsa Possible Site For AMA Regional Meeting . 22

Medical Information Confidentiality Stressed . . 23

San Antonio To Host International Medical As-
sembly ......... 23

One-Third of Health Dollars Spent By Government . 25

Medicare Deductible Up For 1975 .... 25

Fifty Years of Medical Practice .... 27

Death .......... 27

New Doctor’s Office in The State Capitol . . 28

Book Reviews ........ 28

Miscellaneous Advertisements ..... 29

Index To Advertisers ....... xxxvi

Woman’s Auxiliary ....... xxxvii

The Last Word ....... xxxviii

(Cover Art by William Cason )

a basic need for life support

Adverse Reactions: May cause nausea, headache,
cardiac palpitation and CNS stimulation. Post-
prandial administration may help to avoid gastriq
discomfort.

Before prescribing, please review complete prod-
uct information, a summary of which follows:

Indications: For reli^Lot acute bronchial* asthma
and for reversible bronchospasm associated with
chronic bronchitis and emphysema.

Precautions: Exercise caution with use in the
presence of severe cardiac disease, renal or he-
patic malfunction, glaucoma, hyperthyroidism,
peptic ulcer, and concomitant use of other xan-
thine-containing formulations or other CNS stim-
ulating drugs.

How Supplied:

LUFYLLIN, 200 mg., Tablet's: NDC 19-R521-92
bottle of 100; NDC 19-R521-97. bottle of 1000.
LUFYLLIN Elixir: NDC 19-R515-68, pint bottle
NDC 19-R515-69, gallon bottle.

LUFYLLIN Injection: NDC 19-R537-T2, box of 2i
x 2 ml. ampuls.

ON STUFFING CROW

I hope that my colleagues in the upper eche-
lons of the AMA didn’t impair their digestive
tracts during the recent holidays. They will
have a lot of crow to eat and it might prove to
be quite indigestible, especially to the ones
who uttered and wrote those imperious ad-
monitions about raising fees for our profes-
sional services. They are the ones who urged us
to work more efficiently, to operate more
economically, to make some sacrifices and to
lower our standards of living. With wagging
fingers and clucking tongues, they warned us
that Big Brother was watching and would con-
sider the raising of fees sufficient evidence of
felonious greed and criminal selfishness to jus-
tify locking us in chains.

All the while these policy-making leaders,
these spokesmen of our nation’s physicians
were letting the AMA spend itself into bank-
ruptcy. More accurately, it seems they were
pursuing bankruptcy with shocking candor. At
a time when prime interest rates usu-

rious, they were down at the bank, negotiating
a multimillion dollar loan. Then, with an-al-
most-contemptuous air of self-righteousness,
they had the temerity to demand an increase in
our dues and a mandatory assessment in order
to pay off the note and preserve our solvency.

Costs have risen sharply they explained, and
we must reckon with inflation. Also, they have
expanded membership services and benefits in

Journal / January 1975 / Volume 68

such ways as publishing an out-sized, artsy
periodical wherein non-practicing experts in
health care delivery can belabor us with their
counsel. And by attacking groups of physicians
(AAPS) who are critical of many official AMA
positions, deriding the size of their organiza-
tions and the small towns in which its mem-
bers practice. And by railroading debate at
AMA meetings. And by hiring the editors and
reporters and staff assistants skilled enough to
provide these services.

Clearly, it is terribly expensive to alienate
the entire membership of a large organization.
But they have succeeded. And at least they
have been consistent; their judgment has been
unvaryingly bad. They have embraced Medi-
caid, Medicare, PSRO and The Bureaucracy.
They have endorsed fee schedules, medical
merchandising and the piracy of foreign physi-
cians. They have been derogatory of their crit-
ics, suspicious of their friends and inept in
their politics. How perfectly logical that they
now demand gratuities from those who have
been injured.

Nevertheless, I am going to pay to continue
my membership in the AMA. Certainly, I could
never again support mandatory membership,
but to leave the AMA now would be to abandon
a patient at the crisis of his illness. So I am
sending in my sixty dollars. I hope part of it, at
least, pays for the crow. And I will gladly help
stuff it. . .down the deserving throats. MRJ

president' s page

There can be little
doubt that peer review
is both justified and log-
ical — the Oklahoma
State Medical Association
has been carrying on
peer review for profes-
sional services for ap-
proximately nine years.

In fiscal 1972 Americans
spent 7.6% of the gross
national product, or $83.4 billion, on personal
health care — double the amount spent in
1965, much of which (52%) was in keeping up
with inflation. In fiscal 1973 the figure ap-
proached $100 billion. This care was delivered
in 7,000 hospitals, 29,000 nursing homes and
innumerable medical offices by 2xh million
personnel, including almost 400,000 physi-
cians. This vast industry is the largest and
most complex in the United States. Reasonable
cost controls and assurance of quality are not
unreasonable, but the PSRO law has included
sweeping controls that have not been imposed
upon any profession in the United States. No
such mechanism for monitoring health care
has ever been tried in any existing health care
delivery system anywhere. While there is thin
allusion to quality, the main thrust is at cost
control. Administration costs alone are antici-
pated to be some $350 million annually and
possibly more. Any program involving this
much money and this much power will attract
supporters, not only from without the profes-
sion, but — alas — also from within. It is cer-
tain to add to the cost of medical care. Worse
than that are other implications in the bill,
such as "Professional Standards Review Or-
ganizations will have the authority to approve,
in advance, the medical necessity of elective

admissions to institutions, as well as extended
or costly services.”

The entire proposal — now actual law — was
accepted and promoted by our national organi-
zation; true, the organization requested
numerous modifications, but the modifications
have not been forthcoming. The circumspect
procedure would have been to obtain the mod-
ifications before giving support.

On a happier note, I am delighted to report
that our association’s efforts to assist the
Health Sciences Center have been finally pro-
ductive. In addition to putting on our program
in 15 different areas of the state, your Medical
Liaison Committee members and your three
executive directors have had innumerable
meetings with a large number of state legis-
lators, civic leaders, faculty members, Univer-
sity Regents, Higher Regents, President Sharp
and his staff at the University in Norman, na-
tional legislators and Governor Boren. Fine
cooperation has been exhibited on all sides and
I believe the immediate future will reveal a
greater support for our medical school and
University Hospital than has been experienced
in a very long time. I am indeed proud of the
contributions of both time and money that you
have made in this effort. It proves once again
that Oklahoma has a fine medical association.
I am honored to be a member of it. Few associa-
tions have the firmness of purpose, devotion to
duty, loyalty to cause and unity of action as
does ours.

Before closing, I should like to call your at-
tention to the hard work and fine organization
efficiency being exhibited by Chairman Mar-
ion Wagnon and his committee to develop an
outstanding program for Summit ’75 in April
at Lincoln Plaza. Please make the necessary
office adjustments and plans at an early date to
assure attendance.

Oklahoma State Medical Association

scientific

Civilian Vascular Injuries:
A Clinical Review

THOMAS A. MARBERRY
JAMES M. HARTSUCK, MD
G. RAINEY WILLIAMS, MD

Since the volume of civilian vascular
injuries has increased over the last decade,
aggressive surgical management with early
angiography, exploration and operative repair

appears to be justified.

The management of patients with vascular
injuries has become more clearly defined and
the benefits of precise surgical reconstruction of
the vascular system have become apparent as
the result of the extensive clinical experience
gained from wartime vascular trauma9’ 12.
Vascular injuries among civilians have been
less well studied but the clincal problem is in-
creasing with the present higher incidence of
penetrating trauma. As a result of the increased
volume of civilian vascular injuries the need for
clear policies concerning early exploration, an-
giography, and prompt, precise vascular repair
has become evident. Many civilian institutions
have adopted policies of early exploration when
vascular injury is considered likely2 5> 10 ’ 13. In
an effort to evaluate these policies a clinical

From the Department of Surgery, University of Oklahoma Health
Sciences Center, Oklahoma City, Oklahoma.

Oklahoma State Medical Association

review of patients from the University of Ok-
lahoma Health Sciences Center who were oper-
ated upon for possible traumatic vascular in-
jury from the period 1963 through 1972 was
undertaken. An effort was made to correlate the
clinical signs with the actual vascular injury
and to evaluate the results of a liberal policy of
exploration for penetrating wounds near major
vessels.

Review of Clinical Material

The records of all patients at the University of
Oklahoma Health Sciences Center who under-
went surgical exploration for possible vascular
trauma were reviewed for the past ten years.
The patient population included the adjacent
metropolitan area and referrals from the entire
state. Individual cases were considered "posi-
tive” if vascular injury was demonstrated
through surgery and "negative” if no vascular
trauma was found. In both categories the pres-
ence of hematomas, absent distal pulses, and
associated injuries including trauma to nerves,
tendons, and bone was recorded. The method of
surgical reconstruction as well as the value of
angiography both preoperatively and intra-
operatively were evaluated. Patients with only
intra-abdominal vascular injury were excluded
since nearly all patients with penetrating ab-
dominal trauma were routinely explored. A
significant number of vascular injuries due to
diagnostic or therapeutic maneuvers were also
excluded.

The incidence of recognized trauma to the

Injuries / MARBERRY et al

E2 POSITIVE EXPLORATIONS

Table 1

vascular system has increased significantly
over the past decade and dramatically in the
past three years as depicted in Table 1. The total
number of patients undergoing surgery each
year in the Oklahoma Health Sciences Center
has remained relatively constant during this
study. It is noteworthy that the percentages of
negative and positive explorations have re-
mained relatively constant during this ten-year
period.

Analysis of the anatomical site of injury re-
veals that the upper extremity is the most
commonly injured region followed by injuries to

Thomas A. Marberry is a third-year student
at the University of Oklahoma College of
Medicine.

Since his graduation from Harvard Medical
School in 1962, James M. Hartsuck, MD, has
been certified by the American Boards of
Surgery and Thoracic Surgery. He is presently
Clinical Assistant Professor of Surgery at the
University of Oklahoma Health Sciences
Center. He is a Fellow of the American College
of Surgeons, a member of the American Cancer
Society and the Southwestern Surgical Con-
gress.

A 1950 graduate of Northwestern University
Medical School, G. Rainey Williams, MD, has
been certified by the American Boards of
Surgery and Thoracic Surgery. He is Professor
and Chairman of the Department of Surgery at
the University of Oklahoma College of
Medicine. Doctor Williams is Governor of the
American College of Surgeons, Treasurer of the
Southern Surgical Association, a member of the
American Surgical Association, the American
Association for Thoracic Surgery and the Hals-
ted Society.

the neck (Table 2). The fraction of positive exp-
lorations was relatively constant for the various
anatomical sites. Negative explorations were
also investigated in an effort to evaluate the
incidence of "significant” associated injuries
which made the exploration a valuable experi-
ence for the patient. "Significant” associated
injuries were defined as those injuries that were
physiologically significant and surgically cor-
rectable. Total associated injuries included sig-
nificant injuries plus those that were not surgi-
cally correctable, eg, fractures treated by splint-
ing or casting and nerve contusion which re-
sulted in impaired function.

The negative explorations were also
evaluated in an effort to define clinical charac-
teristics of patients with positive and negative
exploration of the various anatomical sites.
Neck injuries were associated with the most
frequent negative explorations (57%). These
neck injuries were commonly accompanied by
hematomas and clinical absence of distal pulsa-
tion even in the absence of significant vascular
injury (Table 3). It is of interest that 3 1% of such
negative explorations had surgically treatable
injuries including two instances of unsuspected
laceration of the esophagus or posterior
pharynx, a spinal cord injury which required
posterior laminectomy, and two instances of
parotid gland injury managed with drainage.
The incidence of significant associated injuries
is higher when vascular disease is demon-
strated by exploration; 45%, when compared to
the 22% incidence of significant injuries as-
sociated with negative vascular exploration.
Significant associated injuries were found in
five of six patients with popliteal area arterial
trauma. Four of these six patients had major
venous injury, four had significant nerve dam-
age and two had associated fractures either of
the proximal tibia or fibula. The analogous
upper extremity brachial artery injuries were
also found to have a high incidence of signific-
ant associated injuries, 70%.

Hematoma was evident with equal frequency
in patients with and without vascular injury.
However, the absence of a palpable distal pulsa-
tion was documented in 57% of patients found to
have significant vascular trauma and only 15%
of those with negative exploration (p < 0.0001
that these are the same in a chi squared test).
Seven patients underwent preoperative an-
giography and later had positive explorations.
The preoperative angiography was diagnostic
of arterial trauma in each of these instances.

Journal / January 1975 / Volume 68

SITE OF INJURY AND ASSOCIATED INJURY

Total

Significant

Associated

Positive

Total

Associated

Significant

Associated

Negative

Total

Associated

Significant

Associated

Vessel

Exploration

Injuries

Exploration

Injuries

Exploration

Injuries

Brachial Artery

Radial Artery
Ulnar Artery

Carotid Artery

Jugular Vein

Femoral Artery

Popliteal &
Tibial Arteries

Thoracic

Iliac Artery

Iliac Vein

TOTALS

115

39 (33.8%)

56(48%)

30(53%)

25(45%)

59(59%)

19(32%)

13(22%)

TABLE 2

Intraoperative arteriography was also of value.
For example, in one instance, routine angiog-
raphy after femoral artery reconstruction re-
vealed a clot at the popliteal trifurcation. This
occlusion was unsuspected clinically and the
demonstration by angiography permitted sim-
ple extraction at the time of operation (Fig 1, 2.)

The majority of patients with vascular in-
juries were managed by resection and reanas-
tomosis (Table 5). It was possible to reconstruct
all of the brachial artery injuries and to estab-
lish pulsatile flow distally. Six of the ten
radial-ulnar injuries involved the ulnar artery
and five of these were ligated without ill effect.
Only one of the four radial artery injuries were
managed by ligation. In the five carotid in-
juries, vascular reconstruction was possible and
adequate flow established. One internal jugular
vein was managed by suture repair and the
other ligated. Two instances of ligation at the
iliac level were performed, one for injury of the
iliac vein and the other for injury to the internal

NEGATIVE EXPLORATIONS:
CLINICAL FINDINGS

Vessel Explorations Hematoma % Absent Vc

Distal

Pulse

Brachial

40%

20%

Radial-

Ulnar

22%

Carotid

Jugular

62%

19%

Femoral

50%

20%

Popliteal-

Tibial

100%

17%

Thoracic

43%

Iliacs

100%

TOTALS

50%

15.2%

TABLE 3

iliac artery. Only four cases of the 56 positive
explorations developed postoperative complica-
tions and required amputation of the involved
limbs. Analysis of these patients includes one
patient admitted 2Vz weeks after a gunshot
wound of the popliteal fossa, two patients with
gunshot wounds to the brachial artery managed

Fig 1: Routine operative arteriogram demon-
strated an unsuspected obstruction of the distal pop-
liteal artery.

Oklahoma State Medical Association

Injuries / MARBERRY et al

POSITIVE EXPLORATIONS:
CLINICAL FINDINGS

Fig 2: Completion arteriogram after Foggarty ex-
traction of popliteal thrombus.

by tourniquet with delayed repair which re-
sulted in progressive ischemia despite success-
ful vascular reconstruction, and a fourth pa-
tient admitted two days following popliteal ar-
tery injury with established gangrene.

Four deaths occurred (3.5%), all in the posi-
tive exploration group. One patient died in the
operating room of hypovolemic cardiac arrest
secondary to transection of the pulmonary ar-
tery before control of the injured vessel could be
achieved. Two other deaths occurred in the
postoperative period and were attributed to
postoperative pulmonary insufficiency. The
fourth death occurred in the operative period
and was due to ventricular fibrillation secon-
dary to hypovolemia as a result of uncontrolled
intra-abdominal bleeding.

Discussion

It is obvious from our clinical review and from
other published studies3’ 411 that the incidence

Absent

# Positive Distal Pre-Op

Exploration Hematoma % Pulse % Arteriogram

Brachial

10%

70%

Radial Ulnar

10%

50%

Carotid Artery

80%

60%

Jugular Vein

57%

14%

Femoral

70%

80%

Popliteal-

Tibial

67%

100%

Thoracic

60%

Iliac Artery

100%

Iliac Vein

100%

50%

TOTALS

48.2%

57%

TABLE 4

of vascular trauma among civilians has in-
creased in the past decade. Since delay in surgi-
cal intervention has been responsible for loss of
limbs as well as increased morbidity, we have
adopted a liberal policy of exploration of penet-
rating injuries adjacent to major vascular struc-
tures as advocated by Patman, Triman, Pearch,
Moore7 9 10, 13. Nevertheless, this liberal pol-
icy for exploration has been accompanied by a
significant number of negative explorations.
Specifically, this has been a common experience
with penetrating trauma of the neck when the
policy of exploration of wounds which penet-
rated the platysma was adopted6.

Analysis of our patients who underwent
negative explorations reveals a very low com-
plication rate without significant morbidity in
59 consecutive cases. The high incidence of
hematoma (50%), and low but significant inci-
dence of clinically absent distal pulses, (15%),
are noteworthy features. Associated injuries

POSITIVE EXPLORATION: TREATMENT

# Positive Reanas- Suture Venous Operation

Vessel Explorations

Ligation

tomosis Repair

Graft

Arteriogra

Brachial

Radial-

Ulnar

Carotid Artery

Jugular Vein

Femoral

Popliteal-Tibial 6

Thoracic

Iliac Artery

Iliac Vein

TOTALS

TABLE 5

Journal / January 1975 / Volume 68

were found in 19 of these 59 negative explora-
tions and 13 of these associated injuries needed
surgical correction. Thus, it appears that the
benefits of the liberal policy of exploration far
outweigh the morbidity.

The management of patients with significant
vascular injuries was extremely successful.
Vascular patency was achieved in all cases in
which restoration of flow was attempted. Only
four patients required amputation and in each
instance delay in vascular reconstruction was a
major factor.

Operative arteriography was not employed
routinely but in selected instances and was ex-
tremely valuable in documenting technical er-
rors or distal intravascular obstruction. Failure
of vascular reconstruction appeared related to
delay in reconstruction in patients with exten-
sive injury1 2.

We conclude that the liberal policy of early
exploration for penetrating wounds adjacent to
major blood vessels should be continued. A high
rate of negative exploratory procedures appears
justified when one considers the minimal mor-
bidity and the significant number of associated
injuries thus discovered. Mufti and his
associates8 have demonstrated both clinically
and experimentally that arteriography may be
unreliable in detecting early arterial injury or
later complications; yet, pre-, intra-, and post-
operative angiography are worthwhile proce-
dures and as advocated by Moore, Perry and
others7’ 11 their indications should be
liberalized.

Summary

A clinical review of 115 patients who under-
went surgical exploration for possible vascular
trauma in the past ten years indicates that the
incidence of civilian vascular injuries is in-
creasing. Aggressive surgical management
with early angiography, exploration, and
operative repair appears to be justified. Al-
though negative explorations are not uncom-
mon, the low morbidity and significant inci-
dence of associated, correctable injuries found,
support this policy. Also, delay in vascular re-
construction is a major factor contributing to
limb loss. The correlation of vessel injury with
anatomic site, hematoma, absent pulse, and as-
sociated injuries is presented. □

REFERENCES

1. Adar R, Nerubay J, Katznelson A, Mozes M: Management of Acute Vascu-
lar Injuries. J Cardiovasc Surg 11: 435-439. 1970.

2. Annetts DL, Harris JD, Jepson RP, Hudbrook J, Miller JH, Trach GD:
Arterial Injuries in Civilian Practice. Aust New Zeal J. Surg 39: 340-345, 1970.

3. Bizer LS: Peripheral Vascular Trauma. Postgrad Med 49: 127-130, 1971.

4. Dillard BM, Nelson DL, Norman HG: Review of 85 Major Traumatic
Arterial Injuries. Surgery 63: 391-395, 1968.

5. Drapanas T, Hewett RL, Weichert RF, Smith AD: Civilian Vascular In-
juries: A Critical Appraisal of Three Decades of Management. Ann Surg 172:
351-360, 1970.

6. Knightly JJ, Swaminathan AP, Rush BF: Management of Penetrating
Wounds of the Neck. Amer J Surg 126: 575-580, 1973.

7. Moore CH, Wolma FJ, Brown RW, and Derrick JR: Vascular Trauma. Amer
J Surg 122: 576-578, 1971.

8. Mufti MA, LaGuerre JN, Pochaczevsky R, Kassner EG, Richter RM,
Levowitz BS: Diagnostic V alue of Hematoma in Penetrating Arterial Wounds of
the Extremities. Arch Surg 101: 562-569, 1970.

9. Patman RD, Poulous E, Shires GT: The Management of Civilian Arterial
Injuries. Surg Gynec Obstet 11: 725-737, 1964.

10. Pearch MB, Drez DJ, Gibson WE, Pearch CW: Management of Acute
Arterial Injuries. Southern Med J 62: 1509-151.3, 1969.

11. Perry MO, Thai ER, Shires GT: Management of Arterial Injuries. Ann
Surg 173: 403-408, 1971.

12. Slaney G, Ashton F: Arterial Injuries and Their Management. Postgrad
Med J 47: 257-269, 1971.

13. Treiman RL, Doty D, Gaspar MR: Acute Vascular Trauma a Fifteen Year
Study. Amer J Surg 111: 469-473, 1966.

P.O. Box 26901, Oklahoma City, Oklahoma 73190

MARK YOUR CALENDAR NOW!

OKLAHOMA MEDICAL SUMMIT 75

April 23rd-26th, 1975— Lincoln Plaza Forum— Oklahoma City

A combined meeting of the Oklahoma State Medical Association, the Oklahoma City Clinical Society and the
Oklahoma Academy of Family Physicians.

Journal / January 1975 / Volume 68

Towards Control of Breast Cancer

In Oklahoma

ARTHUR F. HOGE, MD
G. BENNETT HUMPHREY, MD, PhD

Breast cancer is becoming a controllable
disease. Basic and clinical research are
leading to patient management plans capable
of producing 80 to 85 percent response
rates. The Oklahoma Medical Research
Foundation has established a statewide
demonstration network to disseminate
information to the hospitals of Oklahoma.

When one speaks of cancer control many peo-
ple do not quite understand the meaning. Is it
an enigmatic expression? Is it a real possibility
or merely a challenge? If real progress in the
control of cancer is to occur it almost certainly
would occur in one or more of five specific areas:
prevention, early diagnosis, primary therapy,
rehabilitation, or treatment of advanced dis-
ease.

Research in breast cancer has made some
rather impressive advances in the past decade.
A virus which may have an etiologic role has
been isolated.1 3 The genetic material of this
virus has been identified within the DNA of
some tumor cells4 6 and an immunologic
specificity can be demonstrated with both
human breast cancer and a mouse mammary

Supported by National Cancer Institute Contract #N01-CN-45137 and,
Cancer Planning Program Development, Health, Education and Wel-
fare, P01 C013749 SRC.

cancer.3 7 This does not imply a common causa-
tive role for all breast cancers but certainly
points toward a viral etiology of many. Further
studies in etiologic and immunologic fields
would indicate possible methods of prevention
within the next decade.

Early diagnosis has been enhanced by the
usage of mammography, thermography, and
Xeroradiography (a more refined type of mam-
mography). Screening centers have been estab-
lished across the country and have utilized vis-
ual and palpatory breast examinations together
with the more highly sophisticated methods
mentioned above. These centers have demon-
strated a capability of diagnosing preclinical
lesions with a high degree of success, having a
false-positive rate of only 15% and a false-
negative rate of 10% -15%. 8

When one considers the logistics of screening
large populations, limitations become evident.
Doctor JoAnn Haberman’s screening center at
the Health Sciences Center has been strained in
managing some 10,000 patients yearly. Even
considering the availability of mammography
and Xeroradiography in other institutions
throughout the state, mass screening of over 1.5
million people is still not practical.

Breast self-examination (BSE) has been ad-
vocated by the American Cancer Society for
more than 15 years. The vast majority of breast
lumps should be palpable when they are 0. 5-2.0
cm in diameter if the technique is properly
employed. Patients who have a lesion less than
2.0 cm in diameter and without skin, fascial, or
grossly involved lymph nodes have a 95%
chance of having a five-year disease-free survi-

Journal / January 1975 / Volume 68

val and a 90% chance of achieving a ten-year
disease-free survival.

End results of primary therapy in breast
cancer have changed very little in the past 70
years since Halsted described his procedure for
radical mastectomy. Lesser operations per-
formed prior to that time by other well-known
surgeons were followed by recurrences of a very
high rate in the neighborhood of 60%-80% as
compared to a 45%-50% recurrence rate follow-
ing standard radical mastectomy. National
statistics indicate a slight increase in the inci-
dence of breast cancer in the past 20 years with
a rather constant death rate. This indicates
a slight improvement in the relative sur-
vival rate but is most likely related to earlier
diagnosis. Radical mastectomy, as such, is less
than optimal therapy in patients who have
nodal metastases, as 67% of these patients will
demonstrate recurrent disease within five
years and only 45% will survive more than five
years.10-12 Extending the mastectomy field to
include supraclavicular and internal mammary
nodal areas either by surgical11 13 14 or adjuv-
ant radiation therapy11- 15-17 has not increased
the survival rate. We are now witnessing seri-
ous challenges to this established and accepta-
ble method of therapy. Crile,18 McWhirter,19
Roberts,20 and others have proposed lesser pro-
cedures and a great debate has ensued. The
NSABP clinical trials21 have not shown any
significant difference in survival or develop-
ment of metastases when comparing radical
mastectomy vs simple mastectomy plus radia-
tion therapy or standard radical mastectomy as

Arthur F. Hoge, Jr., MD, who was graduated
from Tulane University School of Medicine in
1949, specializes in oncology. He is Assistant
Professor of Research Medicine at the Universi-
ty of Oklahoma Health Sciences Center. Among
his medical affiliations are the American As-
sociation for Cancer Research, the American
Society of Clinical Oncology, the American Col-
lege of Obstetricians and Gynecologists and the
Southwestern Surgical Congress.

A 1960 graduate of the University of Chicago,
The School of Medicine, G. Bennett Humphrey ,
MD, PhD, is presently Chief of the
Hematology! Oncology Service at Oklahoma
Children’ s Memorial Hospital. He is a member
of the American Academy of Pediatrics, the
American Society of Clinical Oncology, the Soc-
iety for Pediatric Research and the XI Interna-
tional Cancer Congress.

Oklahoma State Medical Association

compared to standard radical mastectomy plus
radiation therapy.

Fisher’s National Surgical Adjuvant Breast
Project has two-year results of a randomized
prospective clinical trial to determine the rel-
ative merits of Halsted radical mastectomy vs
simple mastectomy with or without radiation
therapy. The two-year results reveal essen-
tially no difference in recurrences or the de-
velopment of metastatic disease in the patients
of any of these three limbs. Another protocol
randomizing patients at high-risk for recurrent
breast cancer to mastectomy plus or minus
phenylalanine mustard has produced statisti-
cally significant differences in the recurrence
rates favoring those patients who have had ad-
juvant systemic chemotherapy.22 Only one of
thirty pre-menopausal women treated with
chemotherapy has had a recurrence within two
years whereas 11 of 37 have had recurrences
after surgery alone.

Biological studies of breast cancer have been
most rewarding and probably will lead to ra-
tional changes in our approach to therapy, both
at the time of initial diagnosis and at the time of
first or secondary recurrence.

There are numerous types of breast cancer,
many of which have a considerably different
prognosis than others.23 Intraductal papillary
carcinomas behave considerably different from
infiltrating ductal carcinomas and can be con-
trolled by more limited procedures. Lobular
carcinoma in-situ tumors have a relatively be-
nign course and can be managed more con-
servatively than their more malignant
counterparts. The same can be said of localized
mucinous carcinomas or medullary carcinomas.

The aggressiveness of the tumor can also be
modified by the host resistance and im-
munologic mechanisms. Foote and Stewart24
first suggested the possible immunologic signif-
icance of the presence of lymphocytes in medul-
lary carcinoma in 1946. Tumor specific an-
tigens of breast cancer have been identified on
the cell membrane,25 within the cytoplasm,26
and intranuclear.27- 28 These antigens are cap-
able of inciting both humoral and cell-mediated
responses with the production of auto-
antibodies and sensitized lymphocytes which
are capable of destroying tumor cells in
vitro .29- 30 While antibody studies are effective
means of demonstrating immunologic reactions
and tumor-host relationships, Cytotoxic
antibodies have not been demonstrated in
breast cancer. The tumoricidal immunologic
control mechanisms are mediated through the

Cancer / HOGE, HUMPHREY

thymic oriented group of lymphocytes or
T-cells.30

Hudson31 has demonstrated a decreased titer
of tumor specific antibodies in patients with far
advanced and widespread tumor. We do not feel
that this is in itself a manifestation of im-
munologic failure on the part of the host but is
most likely an absorption phenomenon. Tumor
cells may act as a large sponge and acquire a
coating of antibody onto the cell membranes.
This can effectively hide the antigens from the
circulating T-cells. Tumors are capable of emit-
ting large quantities of soluble antigens with
resultant production of antigen-antibody com-
plexes.

Competence of the cell-mediated immune
system is paramount in considering therapeutic
regimens in patient management programs, in-
cluding surgical therapy, chemotherapy, and
endocrine therapy.33' 36

Studies of non-hormonal chemotherapeutic
agents in the control of breast cancer have
shown tremendous strides over the past 20
years, with the greatest improvement occurring
in the past five years. Many chemotherapeutic
compounds have been utilized successfully as
individual agents.37 These include the alkylat-
ing agents such as nitrogen mustard, cyclo-
phosphamide, phenylalanine mustard, which
can induce remissions in 25%-30% of patients.
Antimetabolites including methotrexate and
5-FU have been effective in 25%-28% of pa-
tients and vinca alkaloids can be utilized with a
response rate of 20%. Greenspan38 in 1966,
utilized the combination of chemotherapy in-
cluding thiotepa and methotrexate with a re-
sponse rate of 60%. Widespread acceptance of
combination chemotherapy developed after
Cooper39 reported his five-drug regimen in
1969. He originally reported a 90% response
rate but many studies have since been com-
pleted and indicate a true response rate of 55%.
Hoogstraten’s Southwest Oncology Group
study40 has been quite noteworthy. This group
encompassed 200 patients and compared differ-
ent dosage schedules utilizing the five-drug
Cooper regimen to a new agent, adriamycin.
The continuous dosage treatment plan was
superior in patients below the age of 55 years
while an intermittent schedule appeared to be
more effective in older patients. This presuma-
bly could be related to estrogen stimulation and
the proportion of cells in growth proliferative

phases of the cell cycle. The median duration of
remission has been nine months in the contin-
uous schedule and 13 months in the intermit-
tent schedule. Adriamycin was shown to have a
remarkable capacity to induce remissions as a
single agent. The total remission induction rate
was 40%. The drawback is a cumulative dose
limitation because of cardiac toxicity and the
relatively short median duration of remission
which is only 4.5 months.

While oophorectomy has been widely ac-
cepted and used as the choice of therapy at first
recurrence since 1896, the addition of ad-
renalectomy or hypophysectomy has been less
favorably received. This was because of the
early high morbidity and mortality associated
with the more extended procedures. This mor-
tality has now been reduced to a very acceptable
rate of less than 2%, and the combination of
oophorectomy and adrenalectomy or
hypophysectomy can be expected to produce
remissions in 44% of the patients.41 The most
appealing thing about endocrine ablation is the
median duration of remissions which is 23
months for the extended endocrine ablation as
compared to the 4-9 months median duration of
remissions in patients treated with
chemotherapy.41 A study of the
adrenalectomy/oophorectomy patients at the
Oklahoma Health Sciences Center42 revealed a
strong correlation of response with competence
of the cell-mediated immune system. Patients
who had or were able to develop a good immune
competence after treatment responded dramat-
ically to this therapeutic regimen, whereas pa-
tients who had a poor immune competence gen-
erally failed to respond to treatment. Ad-
renalectomy and oophorectomy responses favor
those tumors which have a long disease-free
interval, have relatively well-differentiated
cell types, have estrogen binding receptors, and
a good immune competence.

Chemotherapy is more favorable in more ag-
gressive and rapidly growing tumors with a
short disease-free-interval; the presence of an
estrogen-binding receptor is not important.

We felt that combining chemotherapy with
endocrine ablation might encompass an admix-
ture of tumors; however, the chemotherapy is
strongly immunosuppressive. If chemotherapy
is stopped, the immune competence quickly re-
turns and frequently to a heightened level.43, 44
We have now been utilizing extended endocrine
ablation plus limited term combination
chemotherapy for 15 months and have observed

Oklahoma State Medical Association

favorable objective responses in 21 of 25 pa-
tients, a response rate of 83%. We are currently
studying methods of maintaining and ex-
tending the duration of these remissions.

The American Cancer Society has recognized
the large number of people who are surviving
longer periods of time after breast cancer is
diagnosed. They have embarked upon an ex-
tensive program for rehabilitation of these peo-
ple in an effort to return them to normal life-
style patterns. This program involves all as-
pects of sociological, psychological, and physical
rehabilitation efforts and is administered by
carefully selected and trained individuals most
of whom have experienced a mastectomy.

With this brief review we can readily see that
research in breast cancer is beginning to pro-
duce rewards. Improvement in research results
is being reported regularly and it is imperative
that we set up mechanisms whereby this infor-
mation can be readily disseminated to primary
care institutions.

The Oklahoma Medical Research Foundation
has been funded by the National Cancer Insti-
tute for the operation of a Network Demon-
stration Project. The American Cancer Society
has been very instrumental in the development
and assistance in operation of the program.
Twenty-three representative hospitals have
been selected across the state where total man-
agement programs can be initiated. While it is
true that some hospitals may not have the facil-
ities to embark upon some sophisticated pro-
grams, they have access to these through their
established referring patterns. The program
has two major committees as the backbone of
the operation. The first of these is a Develop-
mental Therapy Committee coordinated by
Doctor Michael T. Shaw, a hematologist-on-
cologist with the Oklahoma Medical Research
Foundation and the Department of Medicine,
University of Oklahoma Health Sciences
Center. It is composed of representatives from
the fields of pathology, radiology, and nuclear
medicine; surgery, radiotherapy, and medical
oncology. Many of these investigators are en-
gaged in private practice and have given val-
uable assistance to the program. This commit-
tee investigates both clinical and basic research
protocols and monitors those in other institu-
tions in cooperative group studies. When re-
search protocols have proven to be significantly
better than others now in vogue, the protocol is
re-written into a patient management plan and

submitted through the NCI to a large team of
consultants.

The Consultants Committee is coordinated
by Joseph M. Parker, MD, surgeon and former
President of the American Cancer Society, Ok-
lahoma Division. It is composed largely of
physicians in private practice representing
surgery, radiation therapy, medical oncology,
nuclear medicine and pathology. This group
meets quarterly to evaluate all protocols re-
commended by the Developmental Therapy
Committee and to review all clinical activities
of the program. Representatives of this commit-
tee are to meet with hospital tumor boards at
least once monthly for dissemination of current
knowledge and to act as a multi-disciplinary
team of consultants. In most instances one or
more members of the hospital staff will be a part
of the consulting team. This team of consultants
is also readily available for instant consultation
over a tele-communication network. These con-
ferences can be arranged by calling the Net-
work Project office at the Oklahoma Medical
Research Foundation, area code 405-235-8331,
extension 254.

Other committees which have been appointed
and are active include Professional and Lay
Education Committees, a Nursing Committee,
and Program Evaluation Committee.

The Program has four District Representa-
tives each of whom is a well-educated and spe-
cially trained oncologic nurse. These nurses
meet with tumor boards at each of the hospitals
and are working through the hospital admin-
istration and nursing staff to train oncologic
nurses in each hospital. Oncologic nurses have
the capability of administering cancer
chemotherapeutic agents and will have a full
knowledge of rehabilitation programs, patient
management plans, and experimental protocols
including currently used experimental drugs.

While the ultimate mortality of breast cancer
may require preventive measures not yet avail-
able, we feel that we can initiate long-range
patient management programs which can pro-
vide a productive longevity of survival with
normal life-style patterns. □

BIBLIOGRAPHY

1. Moore, D. H. Evidence for a human breast cancer. Indian J. Ca. 8:80, 1971.

2. McGrath, C. M., and Blair, P. B. Immunofluorescent localization of mam-
mary tumor virus antigens in mammary tumor cells in culture. Ca. Res.
30:1963, 1970.

3. Dmochowski, L. Viruses and breast cancer. Hsp. Prac.:73, Jan. 1972.

4. Spiegelman, S., Axel, R. and Schlom, J. Virus-related RNA in human and
mouse mammary tumors, J.N.C.I. 48:1205, 1972.

5. Spiegelman, S., Axel, R., Baxt, W., Gulati, S. C., Hehlmann, R., Kufe, D.,
and Schlom, J. Molecular evidence for a viral etiology of human cancer. J. B.
Lippincott Co., Philadelphia. Proc. Seventh Nat’l. Ca.Conf.: 21, 1973.

Journal / January 1975 / Volume 68

Cancer / HOGE, HUMPHREY

6. Axel, R., Schlom, J.,and Spiegelman, S. Presence in human breast cancer of
RNA homologous to mouse mammary tumor virus. Nature. 235: 32, 1972.

7. Priori, E. S., Anderson, D. E., Williams, W. C. and Dmochowski, L. Im-
munologic studies on human breast carcinoma and mouse mammary tumors,
J.N.C.I. 48: 1131, 1972.

8. Shapiro, S., Strax, P., Venet, L., and Venet, M. Changes in five-year breast
cancer mortality in a breast cancer screening program. Proc. of Seventh Nat’l.
Ca. Conf. Phil. J. B. Lippincott, 1972, Pp 663-678.

9. Wanebo, A. G., Huvos, and Urban, J. A. Treatment of minimal breast
cancer. CA 33:349, 1974.

10. McLaughlin, C. W. and Coe, J. D. Cancer of the breast — a continuing
challenge. Ann. of Surg. 169:844, 1969.

11. Fisher, B. The surgical dilemma in the primary therapy of invasive breast
cancer: a critical appraisal. Current Problems in Surg. Pp 2-53, Oct. 1970.

12. Say, C. C. and Donegan, W. L. Invasive carcinoma of the breast: prognostic
significance of tumor size and involved axillary lymph nodes. CA 34:468, 197 4.

13. Thai, A. P. The extended radical operation for carcinoma of the breast. In
Segaloff, A. (ed) Breast Cancer (St. Louis, C. V. Mosby Co. 1958), p. 93.

14. Urban, J. A. What is the rationale for an extended radical procedure in
early uses? JAMA 199: 742, 1967.

15. Fisher, B., Slack, N., Covanaugh, P. J., Gardner, B., Ravdin, R. G. Post-
operative radiotherapy in the treatment of breast cancer. Results of the NSABP
Clinical Trial. Ann. Surg. 172: 711, 1970.

16. Fletcher, G. H., Montague, E. D., White, C. E. Evaluation of irradiation of
the peripheral lymphatics in conjunction with radical mastectomy for cancer of
the breast. CA: 21: 791, 1968.

17. Butcher, H. R., Jr., Seaman, W. B., Eckert, C., and Saltzstein, S. An
assessment of radical mastectomy and postoperative irradiation therapy in the
treatment of mammary cancer. 17: 480, 1964.

18. Crile, G. Jr., Conservative treatment of advanced breast cancer. Am. J. of
Surg. 126: 343, 1973.

19. McWhirter, R. Simple mastectomy and radiotherapy in the treatment of
breast cancer. Brit. J. Radiol. 28: 128, 1955.

20. Roberts, M. Maureen, et al. Simple versus radical mastectomy. Lancet 1:
1073, 1973.

21. Fisher, B. Cooperative clinical trials in primary breast cancer: A critical
appraisal. CA31: 1271, 1973.

22. Fisher, B. Breast cancer task force meeting, Washington, D.C. Sept. 30,
1974.

23. Ackerman, L., Butcher, H. R. Surgical pathology, C. V. Mosby Co. (St.
Louis, Pp. 720-759) 1968.

24. Foote, F. W. and Stewart, F. W. A histological classificiation of carcinoma
of the breast. Surg. 19: 74, 1946.

25. Gentile, J. M., and Flickinger, J. T. Isolation of tumor specific antigens
from adenocarcinoma of the breast. Surg. Gyn and Obs. 135: 69, 1972.

26. Loisillier, F., Burtin, P., and Grabar, P. Isolement et caracterisation de
l’auto-antigene responsable de la formation d’auto-anticorps chez les malades
atteints de lesions mammaries. Ann. de L’lnstitut Pasteur 829, 1968.

27. Edynak, E. M., Lardis, M. P., Vrana, M. Antigenic changes in human
breast neoplasia. CA;1457, 1971.

28. Edynak, E. M., Hirshaut, Y., Bernard, M., Trempe, G. Fluorescent anti-
body studies of human breast cancer. J. N.C.I., 48: 1137, 1972.

29. Hellstrom, I., Hellstrom, K. E., Sjogren, H. O. and Warner, G. A. Demonst-
ration of cell-mediated immunity to human neoplasms of various histologic
types. Int. J. Ca. 7: 1, 1971.

30. Richters, A., Sherwin, R. P. The significance of autochronous interaction
with human breast cancer cells in primary tissue cultures. CA 27: 274, 1971.

31. Hudson, M. J. K., Humphrey, L. J., Mantz, F. A. Correlation of circulating
serum antibody to the histological findings in breast cancer. Southwestern
Surgical Congress, May 1974.

32. Smith, R. T. Possibilities and problems of immunologic intervention in
cancer. N. Eng. J. Med. 287: 439, 1972.

33. Hamlin, I. M. E. Possible host resistance in carcinoma of the breast: A
histological study. Br. J. Ca. 23: 34, 1968.

34. Morton, D. L., Haskell, C. M., Pelch, Y. H., Sparks, F. C., Winters, W. D.
Recent advances in oncology. Ann. Int. Med. 77: 431, 1972.

35. Black, M. M. Human breast cancer a model for cancer immunology. Israel
J. Med. Sci. 9: 284, 1973.

36. Cheema, R. A. and Hersch, E M. Patient survival after chemotherapy and
its relationship to in vitro lymphocyte blastogenesis. CA 28: 851, 1971.

37. Carter, S. K. Single and combination non-hormonal chemotherapy in
breast cancer. CA 30: 1543, 1972.

38. Greenspan, E. M. Combination cytotoxic chemotherapy in advanced dis-
seminated breast cancer. J. Mt. Sinai Hosp. 33: 1, 1966.

39. Cooper, R. G. Combination chemotherapy in hormone resistant breast
cancer. Proc. Am. Assoc. Ca. Res. 10: 15, 1969.

40. Hoogstraten, B. and George, S. Adriamycin and combination
chemotherapy in breast cancer. Proc. Am. Assoc. Ca. Res. 15: 279, 1974.

41. Hoge, A. F., Shaw, M. T., Bottomley, R. H., Hartsuck, J. M. Analysis of
therapeutic regimens in advanced breast cancer. JAMA, in press.

42. Hoge, A. F., Hartsuck, J. M., Kollmorgen, G., and Schilling, J. A. Endoc-
rine and immunologic studies of breast cancer, Amer. J. Surg. 126: 722, 1973.

43. Hersh, E. M., Whitecar, J. P., McCredie, K. B., et al. Chemotherapy and
immunocompetence, immunosuppression and prognosis in acute leukemia. N.
Eng. J. Med. 285: 121, 1971.

44. Harris, J., Bagai, R., Stewart, T. Immunocompetence and response to
anti-tumor treatment. New Eng. J. Med. 286: 494, 1972.

825 N.E. 13th, Oklahoma City, Oklahoma 73104

THE UNIVERSITY OF OKLAHOMA

COLLEGE OF MEDICINE

WEEKLY AFTERNOON OF CONTINUING EDUCATION

EVERY WEDNESDAY

January 1st, 1975 through May 28th, 1975

Developed by

The Department of Medicine
Office of Continuing Medical Education for Physicians
University of Oklahoma Health Sciences Center

Registration fee: $30.00 per semester

SECOND SEMESTER SCHEDULE

TIME

CONFERENCE

LOCATION

12:00 to 1:00 P.M.

Medical Grand Rounds

East Lecture Hall
Basic Science Building

1:30 to 2:30 P.M.

Pulmonary Disease Conference

C007 Everett Hospital

1:30 to 2:30 P.M.

Hematology-Oncology Conference

A 001 Everett Hospital

1:30 to 2:30 P.M.

Gastroenterology Conference

C002 Everett Hospital

2:45 to 3:45 P.M.

Pulmonary Problem Case Conference

C007 Everett Hospital

4:00 to 5:00 P.M.

Cardiology Conference

C007 Everett Hospital

4:00 to 5:00 P.M.

Infectious Disease Conference

C002 Everett Hospital

4:00 to 5:00 P.M.

Renal Conference

A27 V.A. Hospital

This program is acceptable for Category 1 credit toward the Physician’s Recognition Award of the
American Medical Association and the American Academy of Family Practice on an hour for hour
basis.

Oklahoma State Medical Association

Laboratory Practices In My cobacteriology:

Results Of A Survey Of Oklahoma Laboratories

DIXIE E. SNIDER, JR., MD
R. LEROY CARPENTER, MD, MPH

The results of a survey of Oklahoma
laboratories indicate that some laboratories
need to change their procedures
and policies regarding tuberculosis
bacteriology work.

I. INTRODUCTION

The isolation and identification of Mycobac-
terium tuberculosis in tissues and body fluids
require special staining techniques, specific
cultural conditions, and a niacin test. Even
more specialized and sophisticated techniques
are required to identify the various species of
"atypical” mycobacteria.1 2 Consequently, the
species identification of "atypical” mycobac-
teria, as well as drug susceptibility testing, are
usually done by only a few larger laboratories.

On the other hand, the practicing physician
would like to have certain laboratory proce-
dures readily available so that he may know as
soon as possible if mycobacteria are present in a
specimen. This knowledge may not only be im-

Journal / January 1975 / Volume 68

portant for treatment of the patient but also for
the protection of the patient’s family and those
caring for him. Because of these considerations
and because fresh specimens are more likely to
yield positive results, physicians often want a
local laboratory to have the capability of iden-
tifying mycobacteria, especially M. tuber-
culosis.

In order to do this properly, the laboratory
should be able to do acid-fast stains, set up cul-
tures, and preferably, perform niacin tests. The
latter test, if positive, nearly always identifies
the organism as M. tuberculosis. It is important
to differentiate disease caused by this organism
from diseases caused by other mycobacteria, be-
cause diseases caused by "atypical” organisms
have not been shown to be communicable and,
therefore, do not require the precautions and
contact investigation necessary when a case of
tuberculosis is discovered.

In order to determine the practices of Ok-
lahoma laboratories regarding mycobacteriol-
ogy, a survey of these laboratories was begun in
October 1973.

II. METHODS

A questionnaire was developed which would
emphasize the most important aspects of
mycobacteriology (Figure 1). After consultation
with laboratory workers, it was decided that the
questionnaire should be brief (one page) and
easily understandable in order to get a response

Survey / SNIDER, et al

RESULTS OF

MYCOBACTERIOLOGY QUESTIONNAIRE
2/18/74

Name of Laboratory (or Hospital, etc.)

Location

Yes

Does your laboratory stain for

mycobacteria?

121

102

Does your laboratory culture for

mycobacteria?

141

THE 82 LABORATORIES DOING

CUL-

TURES, THE FOLLOWING RESPONSES

WERE OBTAINED:

Do you use the niacin test?

Does your laboratory identify the

various Runyon groups of

mycobacteria and M. bovis ?

Does your laboratory do biochemical

tests to identify the different species

of "atypical” mycobacteria?

Does your laboratory confirm any of

the above findings with any other

laboratory?

If so, what laboratory?

Does your laboratory do drug

susceptibility testing on

mycobactieria?

If so, which drugs?

Do you do your mycobacteriology

work under an isolation or

safety hood?

Is the vacuum on this hood checked

frequently?

If so, by whom?

10.

Do you report all new isolations of M.

tuber-

culosis to the state or county health depart-
ment, or do you depend upon others (physician,
nurse, medical records, etc.) to do this?

Report directly 43 Depend on others 39

(52)* (30)

Comments:

*Total if credit is given for laboratories refer-
ring cultures to other laboratories that do report.

FIGURE 1

from as many laboratories as possible. The in-
tent was to determine what types of procedures
the laboratories were performing and no at-
tempt was made in this questionnaire to deter-
mine the methods used.

The names and addresses of all laboratories
in Oklahoma known to the Laboratory Service,
Oklahoma State Department of Health were
obtained. The questionnaire, along with a cover
letter signed by the Oklahoma State Commis-

sioner of Health explaining the purpose of the
questionnaire, was mailed to each laboratory on
the list. Four weeks later a second letter was
sent to those not responding. This was repeated
in another month if no response was received. If
there still was no response, a letter and a copy of
the questionnaire were sent to a public health
nurse in the area. She was asked to contact the
laboratory personally in an effort to obtain the
desired information.

The laboratories at the Oklahoma State De-
partment of Health and Oklahoma State
Sanatorium were not included in this survey.

III. RESULTS

Of 228 laboratories to whom the question-
naire was mailed, a response was obtained from
223 (97.8%). The responses to each question are
shown in Figure 1. All 223 questionnaires were
tabulated to obtain the responses shown for
questions 1 and 2. The responses to questions 3
through 10 were tabulated only for those
laboratories giving a "yes” response to question
2.

As can be seen, only 121 (54%) of the
laboratories stain for mycobacteria. Thirty-
nine (18%) do smears but do not culture.
Eighty -two (37%) of the laboratories culture for
mycobacteria. Sixteen (20%) of the 82
laboratories doing cultures identify "atypical”
mycobacteria by Runyon group and fifteen
identify the species.

All but ten laboratories (12.2%) doing cul-
tures refer these cultures to some other laborat-
ory for further identification and/or confirma-
tion of previous test results. Forty-five of the
seventy-two laboratories referring cultures use
the Oklahoma State Department of Health
Laboratory as their reference laboratory. A pri-
vate laboratory in Oklahoma City was next in
frequency with nine referring laboratories. Six
referred cultures to out-of-state laboratories.
Five laboratories in the Tulsa area referred cul-
tures to the Tulsa City-County Health Depart-
ment Laboratory. Other reference laboratories
received referral cultures from one or two
laboratories.

Only four laboratories in the state perform
drug susceptibility testing on mycobacteria.

Of the 82 laboratories doing cultures, only 30
(36.6%) have an isolation or safety hood. Nine-
teen of these hoods are checked frequently to
determine whether the exhaust fan is working

Oklahoma State Medical Association

properly. (Two laboratories have hoods with UV
light and no ventilation fans.)

Forty-three (52%) of the laboratories report
positive results directly to the Oklahoma State
Department of Health. When one considers that
some laboratories may not report directly but
refer cultures to laboratories that do, there are
still apparently only 62.7% of laboratories that
report findings through laboratory channels.

IV. COMMENTS

The response to the questionnaire was better
than expected. Although it was necessary to
make three mailings and a few visits, it is un-
common to get a 97.8% response in any survey
conducted primarily by mail. We are grateful to
the laboratories in the state for their coopera-
tion. We interpret this response to mean that
the questionnaire itself was acceptable in terms
of brevity and clarity.

It was somewhat surprising that only 54% of
the laboratories reported that they stained
specimens to identify mycobacteria. The reason
for such a low percentage of laboratories per-
forming this test is unclear. It may be because
some persons have the erroneous impression
that, unless the newer fluorochrome technique
is used, the results are unreliable.

In recent years the use of the fluorochrome
staining technique has become more popular.
While this technique is more sensitive and
timesaving, especially if thirty or more speci-
mens are processed daily, the special equipment
required makes it an impractical and un-
economical technique for the small laboratory
to perform.

The older Ziehl-Neelsen technique is rel-
atively easy to perform, inexpensive, and of suf-
ficient reliability to be used as an initial screen-
ing test when tuberculosis is suspected.3 If posi-
tive, a presumptive diagnosis can be made
quickly, often saving the patient from further
diagnostic tests and delayed or inappropriate
treatment. We would encourage more
laboratories, even small ones, to perform this
test.

Although a smear done on a concentrated
specimen which has been decontaminated, di-
gested, and centrifuged has a higher yield of
positive results, the direct smear still has clini-
cal usefulness and can often be as good as a
concentrated specimen, if material is carefully
selected.4

In contrast to the above situation regarding
staining of smears, more laboratories than ex-

pected (82) culture for mycobacteria. The
reason for this is also unclear. It may be that
many medical staffs and/or laboratory super-
visors have encouraged laboratories to have
this capability, even though cultures may be
performed infrequently. Of interest in this re-
gard is the fact that only 32 of the 82
laboratories doing cultures (39%) perform a
niacin test. This is a relatively simple test and,
as previously mentioned, if it is positive the
organism nearly always is M. tuberculosis. If a
laboratory can justify performing cultures for
mycobacteria, it is reasonable to expect that
laboratory to presumptively identify the or-
ganisms as M. tuberculosis by doing a niacin
test.

From the responses to questions 4 and 5, it
will be seen that 16 laboratories identify the
four Runyon groups and 15 laboratories do bio-
chemical tests to identify the species. Most of
these laboratories are larger reference labor-
atories. Unless the species of mycobacteria
growing in culture is identified, an erroneous
diagnosis and inappropriate treatment may re-
sult, since not all atypical organisms are patho-
genic. Therefore all isolations of atypical
mycobacteria should be referred for identifica-
tion. The expense and expertise required for
performing the necessary biochemical tests
make it impractical for all but the larger ref-
erence laboratories to perform them.

The response to question six indicates that all
but 10 of the 82 laboratories performing cul-
tures confirm their results with other
laboratories. This is encouraging. However, two
laboratories were found which did not do niacin
or any other biochemical tests and which also
did not confirm their findings with any other
laboratory. These laboratories should either
begin to refer their cultures or begin to do the
procedures required to identify the species of
mycobacteria if the physician receiving the re-
sults is to make an accurate diagnosis.

Only four laboratories reported doing drug
susceptibility studies. This is certainly a suffi-
cient number for the state. Here again, the ex-
pense and expertise required for these studies
make it impractical for all but the larger ref-
erence laboratories to perform them. Three
laboratories performed susceptibility tests to
streptomycin, para-aminosalicylic acid,
isoniazid, and ethambutol; two to rifampin; and
one each to viomycin and ethionamide. One
laboratory failed to state which drug suscept-
bility studies were done.

Oklahoma State Medical Association

Survey / SNIDER, et al

One explanation for the small number of
laboratories doing niacin tests and other bio-
chemical tests may be that only thirty
laboratories reported having an isolation or
safety hood. Laboratories without hoods may be
reluctant to manipulate cultures or do niacin
tests using cyanogen bromide. Apparently
these laboratories are not reluctant to handle
specimens and set up cultures. Tuberculosis is
spread by the airborne route and unfortunately,
many procedures in the laboratory can produce
infectious aerosols even though cultures are not
manipulated.7- 8 It would appear from previous
statements9- 11 that workers handling myco-
bacteria-containing specimens are at increased
risk of developing active tuberculosis. There-
fore, we would encourage all laboratories which
regularly handle specimens for mycobac-
teriology work to utilize the safety measures
which have been previously published.12- 14

Of these thirty hoods, nineteen are checked
frequently to determine whether the exhaust
fan is functioning properly. Hoods should be
checked every three months.5 The exhaust fan
should have the capacity to draw a minimum of
50 to 75 lineal feet of air per minute across the
entire front opening.6 Presumably nine hoods
are not checked and may be ineffective.

In spite of the fact that reporting of tuber-
culosis is required, only 43 of 82 laboratories
doing cultures report positive findings directly
to the Oklahoma State Department of Health.
The Oklahoma Public Health Code (Art. 5, Sec.
1-503) states "(a) The State Board of Health
shall promulgate rules and regulations estab-
lishing a system of reporting cases of diseases
diagnosed or detected by practicing physicians
and/or clinical laboratories which come within
the purview of this article . . If one considers

indirect reporting, there are still only 52
laboratories that report their findings through
laboratory channels. The other laboratories in-
dicated that they depend upon others, primarily
physicians, to report positive findings. While
this is understandable, it often leads to delayed
reporting or failure to report a case of tuber-
culosis.

Perhaps the reluctance to report findings di-
rectly results from a fear of violating the
physician-patient relationship and/or the feel-
ing that the laboratory cannot make a diagnosis
but can only report test results. Regarding the
first consideration, the patient-physician rela-

tionship should not take precedence when the
law specifies that a communicable disease be
reported. In addition, the policy of the Tuber-
culosis Division of the Oklahoma State De-
partment of Health is to contact the private
physician before contacting patients or their
families. Secondly, the intent of the Oklahoma
legislature was for laboratories to report posi-
tive findings, otherwise the statement "cases of
disease . . . detected by . . . clinical
laboratories” would not have been included in
the Public Health Code.

The Oklahoma State Department of Health
needs more rapid and complete reporting be-
cause it has the responsibility to (1) see that
infectious cases are under treatment, (2) inves-
tigate contacts of active cases, and (3) collect
information about the occurrence and incidence
of tuberculosis in our state. If a case is not re-
ported, the patient may be lost to follow-up and
not receive adequate treatment if he moves or
fails to return to his private physician. This
could result in the infection of more persons
with M. tuberculosis. These individuals then
become the reservoir from which more active
cases will develop in the years ahead. Examina-
tion of the contacts of active cases of tuber-
culosis is done to find others who might have
been infected and may have active disease. This

A 1969 graduate of the University of Louis-
ville School of Medicine, Dixie E. Snider, Jr.,
MD, has been certified by the American Board
of Internal Medicine. She is presently Chief,
Research and Development Branch, Tuber-
culosis Control Division, Bureau of State Ser-
vices, Center for Disease Control in Atlanta.
Other medical affiliations include the Ameri-
can Thoracic Society. Doctor Snider was for-
merly Tuberculosis Medical Officer, USPHS,
assigned to the Oklahoma State Department of
Health.

R. LeRoy Carpenter, MD, MPH, was
graduated from the University of Kansas
School of Medicine in 1956. He is Commis-
sioner, Oklahoma State Department of Health
and Adjunct Assistant Professor of Biostatistics
and Epidemiology at the College of Health,
University of Oklahoma Health Sciences
Center. His medical memberships include the
Association of State and Territorial Health Of-
ficers, the Conference of State and Provincial
Health Authorities of North America, the Ok-
lahoma State Thoracic Society and the Ameri-
can Association of Automotive Medicine.

Journal / January 1975 / Volume 68

contact investigation may be neglected if the
case is not reported.

V. CONCLUSION

The results of this survey indicate that (1)
more laboratories should be staining slides for
mycobacteria, (2) fewer laboratories should at-
tempt to culture mycobacteria, (3) laboratories
that do cultures should perform niacin tests, (4)
more laboratories need safety hoods, (5) safety
hoods in existence should be checked more fre-
quently, and (6) direct laboratory reporting to
the Oklahoma State Department of Health
needs to be improved.

We encourage persons responsible for estab-
lishing laboratory policies and procedures to
critically review their practices regarding
mycobacteriology work. Some laboratories will
need to change the types of procedures they
perform and/or how they perform them. In this
way the laboratory will assist the physician in
making a more rapid and accurate diagnosis

and thus provide better treatment for the pa-
tient.

REFERENCES

1. Kubica, G. P., and Dye, W. E.: Laboratory Methods for Clinical and
Public Health Mycobacteriology. U.S. Dept, of Health, Education, and Wel-
fare. PHS Publication No. 1547, 1967.

2. Vestal, A. L.: Proccedures for the Isolation and Identification of
Mycobacteria. U.S. Department of Health, Education, and Welfare. DHEW
No. (HSM) 73-8230, 1973.

3. Ibid.: p. 27.

4. Tarshis, M. S.: "Bacteriology of the Mycobacteria.” Diagnosis and Treat-
ment, Pfuetze, K. H., and Radner, D. G., eds. Charles C. Thomas, Springfield,
111., 1966, p. 39.

5. Vestal, A. L.: Ibid., p. 5.

6. Ibid.: p. 4.

7. Ibid.: p. 1.

8. Tomlinson, A. J. H.; "Infected Air-Borne Particles Liberated on Opening
Screw-capped Bottles.” Brit. Med. J. 2:15, 1957.

9. Reid, D. D.: "Incidence of Tuberculosis Among Workers in Medical
Laboratories.” Brit. Med. J. 2:10, 1957.

10. Pike, R. M., Sulkin, S. E., and Schulze, M. L.: "Continuing Importance of
Laboratory-Acquired Infections.”: Amer. J. Public Health. 55:190, 1965.

11. Long, E. R. "The Hazard of Acquiring Tuberculosis in the Laboratory.”
Amerc. J. Public Health, 41:782, 1951.

12. Vestal, A. L.: Ibid. pp. 1-10.

13. Handbook of Tuberculosis Laboratory Methods, Veterans Admin-
istration: Armed Forces Cooperative Study on the Chemotherapy of Tuber-
culosis, 1962.

14. Wedum, A. G.: "Control of Laboratory Airborne Infection.” Bact. Rev.
25:210, 1961.

1Chief, Research and Development Branch, Tuberculosis Control Division, Bu-
reau of State Services, Center for Disease Control, Atlanta, Georgia 30333. (At
the time of this survey Dr. Snider was a Tuberculosis Medical Officer in the U.S.
Public Health Service assigned to the Oklahoma State Department of Health.)
Commissioner, Oklahoma State Department of Health.

Center for Disease Control, Atlanta, Georgia 30333

INTERNAL MEDICINE REVIEW COURSE

1975

East Lecture Hall, Basic Science Education Building
University of Oklahoma College of Medicine, Oklahoma City, Oklahoma

Developed by

The Department of Medicine, University of Oklahoma Health Sciences Center

and

Office of Continuing Medical Education for Physicians
Registration Fee; $15.00 per semester

Send Advance Registration to: Office of Continuing Medical Education for Physicians, University of
Oklahoma Health Sciences Center, P. O. Box 26901, Oklahoma City, Oklahoma 73190

DATE TITLE — SPEAKER

January 22, Pulmonary Disease II — C. Dowell Patterson, MD
January 29, Diabetes, Hypoglycemia and Calcium — James Males, MD

February 5, Metabolic and Respiratory — Robert D. Lindeman, MD; Acid Base Distrubances — Chris E.
Kaufman, MD

February 12, Glomerulopathies Diagnosis and Management — Solomon Papper, MD; Anil K. Mandal, MD
February 19, Urinary Tract Infection and Stones; Diagnosis and Management — Anthony Czerwinski, MD
February 26, Infectious Disease I — Infectious Disease Section.

March 5, Infectious Disease II — Infectious Disease Section

March 12, Valvular Heart Disease — Eliot Schechter, MD

March 19, Gastroenterology I — Gastroenterology Section

March 26, Congenital Heart Disease In The Adult — Lofty L. Basta, MD

April 2, ASCVD and Cardiomyopathies — Stephen D. Shappell, MD

April 9, Gastroenterology II — Gastroenterology Section

April 16, Metabolic Disorders Presenting In The Adult — Sylvia Bottomley, MD

April 23, Pituitary Adrenalin and Endocrine Hypertension — David C. Kern, MD

April 30, Thyroids and Gonads — E. William Allen, MD

Journal / January 1975 / Volume 68

News From
e Oklahoma State
Department of
Health

PKU REVISITED

Although phenylketonuria is a rare inborn
error of metabolism, enough children have been
successfully managed to be optimistic about the
results. Therefore, we must improve our diag-
nostic methods to avoid a tragic oversight. True
to the maxim that more mistakes are made by
not looking than not knowing, we should check
every newborn infant. Using the Guthrie test as
a screening procedure is not enough. As a
screening test it has limitations which are
magnified by drawing the specimen under 72
hours of age and in cases where the initial pro-
tein intake may be in question because of dif-

ficult early feeding. One can expect false posi-
tive tests in any procedure used for screening
and, troublesome as it may be, a false positive is
easier to explain than a false negative.

Please consider rechecking all infants with
an initial Guthrie test of over 4 mg % im-
mediately, not waiting until four to six weeks of
age. Also, plan to recheck infants who were
tested before 72 hours of age. Seriously consider
rechecking babies who had trouble feeding or in
breast fed babies with questionable intake.
Some physicians are repeating the Guthrie test
at the routine one month checkup.

The intelligence and behavior of an affected
child seems to be optimal when limited dietary
phenylalanine therapy was started under 21
days of age. The Oklahoma State Department of
Health is ready to assist you in the early diag-
nosis of this treatable disorder. Treatment cen-
ters are available at Tulsa’s Children’s Medical
Center, and in Oklahoma City through
Children’s Memorial Hospital. □

COMMUNICABLE DISEASES IN OKLAHOMA FOR NOVEMBER, 1974

DISEASE

November

1974

November

1973

October

1974

Total To Date
1974 1973

Amebiasis

Brucellosis

—

Chickenpox

129

1006

1331

Encephalitis, Infectious

101

Gonorrhea (Use Form OBH-228)

970

752

1072

10385

9995

Hepatitis, A, B, Unspecified

117

950

1053

Leptospirosis

—

Malaria

—

Meningococcal Infections

Meningitis, Aseptic

103

Mumps

405

468

Rabies in Animals

155

Rheumatic Fever

—

Rocky Mountain Spotted Fever

—

Rubella

182

Rubella, Congenital Syndrome

—

Rubeola

—

Salmonellosis

255

263

Shigellosis
Syphilis, Infectious

174

185

(Use Form ODH-228)

133

160

Tetanus

—

Tuberculosis, New Active

271

302

Tularemia

Typhoid Fever

—

Whooping Cough

—

For Consultation Call: (405) 271-4060

Oklahoma State Medical Association

news

Dues and Finances Dominate AMA House of Delegates Meeting

Extended debate, often heated, took place
during the American Medical Association’s
28th Clinical Convention in Portland, Oregon,
November 30th-December 4th. The dispute re-
volved around the financial situation of the
AMA.

The house was reminded that the AMA had
operated at a deficit for four of the last five
years, and that its cash reserves had been seri-
ously depleted during that time. In addition,
AMA finances in 1974 were adversely affected
by inflationary pressures.

After almost six hours of comment and delib-
ration on Tuesday afternoon and Wednesday
morning, the delegates adopted a $60 special
assessment as a stop-gap measure. The man-
datory assessment, effective January 1st, will
be billed from the AMA Washington office to all
members, excluding students, interns and resi-
dents.

The $60 assessment is expected to improve
the immediate cash flow problems for the as-
sociation and to help build up its depleted fi-
nancial reserves.

The house rejected a $90 dues increase pro-
posed by the AMA’s Board of Trustees. In doing
so, however, they called for a special committee
of the house to study the dues issue and report
back at the 1975 Annual Meeting in Atlantic
City. The committee will make a comprehen-
sive study of the AMA’s financial priorities and
capabilities. In the meantime, the house urged
the board to restore in a "holding pattern” the
structure of several councils and committees
which it had previously eliminated, and to
maintain present publication schedules for
JAMA, all specialty journals and Prism.

In a related issue, the house approved adver-
tising as a legitimate function in AMA publica-
tions, and urged that the present full and unre-
stricted advertising program in AMA publica-
tions continue pending further study and a re-
port at the June meeting.

Meeting a total of 16 hours and 40 minutes,
one third of it devoted to the AMA finances

Journal / January 1975 / Volume 68

and related issues, the delegates acted on 77
reports and 68 resolutions for a total of 145
items of business. The following is a brief de-
scription of some of the highlights of the meet-
ing.

Harry Schwartz, PhD, visiting professor of
Medical Economics at the Columbia University
College of Physicians and Surgeons was se-
lected to receive the AMA’s Laymens’ Citation
for Distinguished Service. Doctor Schwartz is
on leave from the Editorial Board of the New
York Times and is the author of the Case for
American Medicine.

Doctor Schwartz will be presented his award
at the 1975 Annual Meeting in Atlantic City.
Last year he was a guest speaker during Ok-
lahoma Medical Summit, the combined annual
meeting of the OSMA, Oklahoma Academy of
Family Physicians and the Oklahoma City
Clinical Society.

During a discussion of malpractice problems,
the house adopted a recommendation calling for
the board to give "priority attention” to provid-
ing legal counsel and advise to AMA members
and state societies in the event their profes-
sional liability insurance is not renewed. The
necessity for state associations to seek legisla-
tive remedies for malpractice problems was
emphasized.

A separation of the fall business meeting of
the house and the scientific meetings will be
permitted beginning in 1977. Under new by-
laws changes the house will hold its fall meet-
ing separately in cities recommended by the
Board of Trustees and selected by the house,
and the scientific session will hold regional
meetings at other times during the years
deemed necessary by the board and at cities
selected by the board. This new format was de-
vised to allow regional scientific programming.
The scientific assemblies will continue to be
held in conjunction with the annual meetings,
however.

Strong programs of continuing medical edu-
cation and peer review as alternatives to re-

news

licensure were called for by the house. Specific
recommendations included all possible encour-
agement for medical professional organizations
to expand the continuing medical education
programs. Well designed peer review programs
would be endorsed as an important component
of performance evaluation, the house stressed
performance evaluation, rather than knowl-
edge per se, as the best method of appraising
competence in patient care.

A vote of confidence was given to the Board of
Trustees by the delegates for its effort to de-
velop new approaches to National Health In-
surance while maintaining traditional AMA
goals. The house adopted a board report con-
taining basic guidelines for NHI deliberations.
(These guidelines are outlined in another arti-
cle in this issue of The Journal.)

A strong policy position against the use of
human chorionic gonadotropin for use in
weight reduction was taken. The house re-
solved, "that the AMA warn our citizens about
the potential danger of such weight control pro-
grams.” Clinics utilizing chorionic gonadotro-
pin have been established and widely adver-
tised in various parts of the country, including
Oklahoma City.

An AMA policy to encourage insurance
coverage of the newborn from the moment of
birth was reaffirmed by the delegates. They
urged the Health Insurance Industry to offer
coverage for obstetrical care and any compli-
cations, and recommended that the insurance
industry, as well as government, offer such
coverage on the broadest possible basis.

State legislation to regulate the practice of
acupuncture was supported by the delegates. A
new policy says acupuncture should only be per-
formed in research settings by a physician or
under the direct supervision of a physician.

The house again objected to language in in-
surance letters indicating that claims were "not
medically necessary,” since this encourages pa-
tients to decline to pay for services and is de-
famatory to physicians.

The present 55-mile per hour speed limit was
endorsed by the house while delegates urged
the government to continue the reduced limit
for at least a one-year period. It noted that
traffic fatalities have declined 14.8% since the
speed limit was imposed last year.

A proposal to replace the Council on Legisla-
tion and many functions of the American Medi-

cal Political Action Board of Directors with a
new Council on Public Affairs was soundly de-
feated by the House of Delegates. Although it
was proposed by the AMA’s Board of Trustees,
many delegates felt that the AMPAC Board
should remain separate from functions of the
AMA. □

Washington Political Profile for 1975

There can be little doubt that the 1974
elections changed the political profile of the
nation’s capital. Going into the election the
United States Senate held 58 Democrats and
42 Republicans while the House of Represen-
tatives had 248 Democrats and 187 Republi-
cans.

Following the November elections it was
clear that the Republicans had suffered
numerous defeats, but had not given the
Democrats the landslide victories that they
anticipated. On November 5th, 34 Senate
seats were contested, of which 20 were held
by Democrats and 14 by Republicans. Of the
20 Democrats, three were unopposed. On
election day, four seats formerly held by Re-
publicans were captured by Democrats and
one seat formerly held by a Democrat was
captured by a Republican for a net gain of
three Democratic seats.

In 1975 the United States Senate of the
94th Congress will hold 61 Democrats and 38
Republicans.

All members of the House of Representa-
tives run every two years. In the 435 House
races, 44 candidates were unopposed. On
election day, 49 seats formerly held by Re-
publicans were taken by the Democrats and
six seats formerly held by Democrats were
captured by Republicans. This gives the
Democrats a net gain of 43 House seats so
that House lineup for the 94th Congress will
be 291 Democrats and 144 Republicans. (At
the time of this writing one House seat in
Louisiana is still being resolved.)

In state governor races, Democrats went
into the elections with 31 governors’ chairs
while the Republicans held 19. Following the
elections, the Democrats held 31 chairs, the
Republicans retained only 13, and one Inde-
pendent was elected. This was a net gain of
five Democratic governships. □

Oklahoma State Medical Association

BEVERLY HILLS HOSPITAL
BEVERLY HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

A Private 115 bed psychiatric hospital located in Oak Cliff on 18 acres amidst natural wooded sur-
roundings. A multi-approach treatment center of neurologic and all psychiatric disorders. Treatment
modalities include Somatic Therapy, Milieu Therapy, Chemotherapy, Individual and Group Therapy,
Transactional Analysis, Gestalt, and Behavior Modification. Complete facilities for OT-RT under the
division of trained personnel. An individually directed program based on full diagnostic evaluation and
actual performance administered by a staff skilled in special education and problems of the adoles-
cent and young adult.

PSYCHIATRY

Jackson H. Speegle, MD Fred H. Jordan, MD

John T. Holbrook, MD Joseph H. Lindsay, MD

PSYCHOLOGY

George R. Mount, PhD Tom I. Payton, MS

Donald L. Whaley, PhD Patrick R. Barnes, MS

EDUCATION DIRECTOR

William E. Nix, PhD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND R.T. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

Journal / January 1975 / Volume 68

neuos

Ford Announces Administration’s
Health Insurance Plan

President Gerald Ford has indicated that
the National Health Insurance Plan his ad-
ministration will submit to the next Congress
will be similar to former President Nixon’s
Comprehensive Health Insurance Plan,
known as CHIP. In a legislative message to
the lame duck congress in late ’74, Ford
made it clear he expected no action during
that year and that he wanted Congress to
wait to see his plan.

CHIP was based on manadatory coverage
of workers by employers through the existing
private health insurance system. While the
original plan had very little congressional
support, it was highly favored by the HEW
leadership.

In the meantime, HEW Secretary Casper
Weinberger has been meeting with the prin-
ciple medical and health care providers, in-
cluding the AMA, in an effort to arrive at
some sort of consensus with respect to an
NHI Bill.

The AMA has provided the secretary and
other organizations with a 14 point set of
principles that it believes essential to any na-
tional health insurance plan. Approved by
the AMA’s Board of Trustees, these NHI
guidelines are as follows:

1) Minimum federal involvement in admin-
istration of any national health insurance
program . . .

2) State jurisdiction with respect to licen-
sure and certification of professional health
personnel and regulation of insurance . . .

3) Minimum federal dollars in financing of
programs for comprehensive coverage at the
least possible cost . . .

4) Funding through federal, state and pri-
vate funds including employer-employee con-
tributions for private health insurance and
an individual tax credit as applied for full
health care protection . . .

5) No added Social Security tax for financ-
ing .. .

6) No administration by the Social Security
Administration . . .

7) Cost sharing by participating individuals
and families and a subsidy for the indigent
scaled according to income . . .

8) Use of private insurance on risks and
underwriting basis . . .

9) Comprehensive coverage, basic and
catastrophic, for the entire population . . .

10) Pluralism in methods of health care de-
livery . . .

11) Cost controls as appropriate . . .

12) Quality controls as appropriate . . .

13) Continuity of benefits . . .

14) Coordination of benefits. □

Tulsa Possible Site
For AMA Regional Meeting

Tulsa has been selected by the AMA’sUouncil
on Scientific Assembly as a potential site for a
Regional Continuing Medical Education Meet-
ing in 1976.

Regional meeting sites are chosen on the
basis of physician-population, ease of trans-
portation access, and availability of physicial
facilities and course faculty. The council has
tentatively selected the month of January,
1976, for a Tulsa presentation.

The regional meeting is presented on a
Saturday-Sunday weekend to minimize the
physician time away from his practice. Each
meeting is composed of six to eight post-
graduate courses on broadly related clinical
topics.

It is possible for a physician to take two
courses with a total of 12 hours of Category I
Continuing Medical Education credit toward
the AMA’s Physicians Recognition Award.

An all encompassing fee "package” is avail-
able to cover room, food and registration. The
fees are collected by the AMA which also bears
the cost of planning and putting on the meeting.

The concept of the regional Continuing Edu-
cation Meeting is part of an expanded program
for which the Council on Scientific Assembly of
the AMA is responsible. The council is the
AMA’s principle programming arm in Contin-
uing Medical Education, an outgrowth of its
traditional responsibility for programming the
scientific and education portions of the AMA
Annual and Clinical Conventions.

During the Portland Clinical Convention the
AMA’s House of Delegates moved for the sep-
aration of the Fall Business Meeting of the
house and the scientific meetings. This will
begin in 1977. It is anticipated that the scien-
tific meetings of the Clinical Convention will be
replaced by the Regional Continuing Education
Programs. The scientific assemblies will con-
tinue to be held in conjunction with the annual
meeting, however. □

Oklahoma State Medical Association

Medical Information
Confidentiality Stressed

Confidentiality of medical information, in
light of computer technology and vast govern-
ment involvement in health delivery, is be-
coming a national concern. The most recent
voice heard was that of the American Medical
Record Association during its annual meeting
in San Francisco.

A position paper outlining the association’s
stand on medical information was adopted by
its House of Delegates. The paper, as originally
published, is as follows:

"The American Medical Record Association
throughout its history has recognized the
patient’s right to privacy in relation to his med-
ical record. While the patient does not have the
property right to his record, he does have the
protected right of information.

"The primary purpose of the medical record is
to document the course of the patient’s health
care and to provide a medium of communication
among direct care professionals for current and
future patient care. Unless the patient can feel
assured that the highly sensitive and personal
information he shares with health care profes-
sionals will remain confidential, he may with-
hold information critical to his treatment,
thereby diminishing the quality of the care pro-
vided him.

"Economic and social issues, together with
technological advances, have resulted in an
erosion sf the confidential relationship tradi-
tionally existing between patient and health
care professional. Substantiation of claims for
payment has generated an ever increasing
number of requests for information from pa-
tient health records. At the same time, the tre-
mendous growth of computerized health data,
the development of huge data banks and the
advancement in record linkage pose an enorm-
ous threat to the privacy of medical informa-
tion. The public is generally unaware of this
threat or of the serious consequence of a loss of
confidentiality in the health care system. Ade-
quate measures to control medical privacy in
the light of electronic information processing
can and must be established.

"The American Medical Record Association
recognizes the need for patient health informa-
tion in providing a sound basis both for substan-
tiating claims and for conducting medical care
evaluation. Therefore, subject to applicable
legal provisions, release of any individually

identifiable medical information for any pur-
pose other than patient care must be done only
with the expressed authorization of the patient
or his legal agent.

"Further, AMRA recommends greater em-
phasis on the patient’s right to privacy by
health care institutions through the establish-
ment of written policies for the release of infor-
mation, together with active educational pro-
grams for all staff personnel, to enforce these
policies.

"With respect to the right of privacy, AMRA,
urges the development and implementation of
programs to: (1) protect the patient from inva-
sion of privacy as a result of indiscriminate and
unauthorized access to confidential health in-
formation and (2) promote applicable usage of
medical information once it is disseminated to
authorized persons.” □

San Antonio To Host
International Medical Assembly

Historic San Antonio will play host for the
International Medical Assembly of Southwest
Texas. The 39th Annual Meeting will be held
in San Antonio’s Saint Anthony Hotel and
the University of Texas Medical School,
Thursday and Friday, February 27th and
28th.

This year’s program is dedicated to the
American Academy of Family Physicians,
with built in interest for the specialists. Nine
outstanding guest speakers have been ob-
tained along with panels composed of local
experts from the University of Texas Medical
School at San Antonio, Wilford Hall Medical
Center, Brooke Army Medical Center and the
Bexar County Medical Society.

At the conclusion of the two-day conven-
tion, the annual extension trip will be to
Acapulco and Mexico City. This trip has be-
come an integral part of the postgraduate
medical seminar and the number of physi-
cians and their wives going on the trip has
increased every year.

Distinguished speakers for the Medical As-
sembly include an Oklahoman, David C.
Kem, MD, an Oklahoma City internist.

Persons interested in receiving additional
details should write Mr. Sid Cockrell, Jr.,
Executive Director, P.O. Box 12678, San An-
tonio, Texas 78212. □

Journal / January 1975 / Volume 68

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance
Springfield, Mass.

For additional details and application form, please contact

Phil Payne

Administrator

720 N.W. 50th Telephone 405 848-7661

P.O. Box 18593 Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

DOCTOR, WHAT WILL YOU EARN?

It depends, of course, on your age and annual earnings, but the amount can quite reasonably
exceed $400,000.

The total value of all your possessions — property, savings, cars and personal belongings —
is only a fraction of what you will probably earn during years of practice. And yet some of you have
insured these things and left your earning power unprotected.

Is this logical? Not when you can participate in the . . .

O.S.M.A. GROUP DISABILITY INCOME PROGRAM

Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION
. . . gives you individual coverage at low group rates.

. . . offers flexible waiting periods at your option.

. . . guarantees you an income when you are disabled from an accident or sickness.

. . . offers optional Indemnity from $200.00 to $2,500.00 per month.

. . . pays for lifetime on accident and up to age 65 on sickness.

For Additional Information, call or write

Phil Payne, Jim Thaxton or Rodman A. Frates
C. L FRATES & COMPANY, INC.

720 N.W. 50th P.O. Box 18695
OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848-7661

Oklahoma State Medical Association

One-Third of Health Dollars
Spent By Government

Of every health care dollar spent in this
country, 33 cents is being provided by the
federal government, according to a unique
report made annually by the AMA’s Wash-
ington office.

Actual dollar outlays in any given year
may vary considerably from the appropri-
ations provided by Congress, but the appro-
priations figure used by the AMA is an accu-
rate guideline of the nation’s year to year
health spending.

During the fiscal year that ended last July,
the federal government disbursed more than
$32.7 billion for health, up $2.6 billion from
the previous year, plus more than $12 billion
for disability programs. Total spending from
all sources on health was estimated at about
$100 billion.

The federal tab for the current fiscal year,
ending in July, 1975, is slated to register a
sharp jump as new federal programs get
going and increased overall health care costs
are reflected.

As was to be expected, the HEW Depart-
ment leads the list of government health
spenders with $23.7 billion appropriated last
fiscal year for its many health activities in-
cluding Medicare and Medicaid. Next in line
were defense and veterans administration,
each spending over $3 billion.

Fourth and fifth slots are occupied by rel-
atively recent federal activities, the Federal
Employees Health Insurance Program and
the Environmental Protection Agency, with
$696 million and $528 million respectively.

Animal disease control, research, meat in-
spection, and a few other lesser activities
under the Department of Agriculture add up
to $302 million per year. Even though it
might be considered a health cost, the AMA
did not count $7.8 billion for health related
programs of food for school children, and
rural housing, water and waste disposal ac-
tivities.

Medicare is the single largest federal
health plan moneywise though financed out
of Social Security taxes. Technically, Medi-
care remains an appropriation that must be
approved by Congress each year. Last fiscal
year Medicare spent $12.1 billion, a $2.5 bil-
lion increase due to increased utilization,
higher costs, and a new program for the dis-

abled, including kidney disease patients,
which accounted for an additional $1.25 bil-
lion.

Of the Medicare total, almost $3 billion
was paid out for the supplemental insurance
plan for outpatient benefits. Half of the pre-
mium is paid for by the beneficiaries.

The federal government allotted $5.8 bil-
lion to the states for the Medicaid Program
for medically indigent people, an increase of
almost $1 billion due to expansion of cate-
gories eligible for such assistance. If federal,
state and local funds are counted, Medicaid
cost $10.5 billion. □

Medicare Deductible Up For 1975

The Department of Health, Education and
Welfare has announced that commencing
with the first of the new year the medical
hospital deductible will jump to $92. The
present deductible is $84.

HEW said that the $92 deductible is equi-
valent to the average cost of one day of hos-
pitalization. The increased payment was
brought about by rising hospital costs, ac-
cording to the department.

The Medicare law requires an annual re-
view of hospital costs under Medicare and an
adjustment of the portion of the bill for which
a Medicare beneficiary is responsible, if the
costs have risen substantially.

When the hospital deductible amount
changes, the law requires comparable
changes in the dollar amounts that a Medi-
care beneficiary pays toward a hospital stay
for more than 60 days, or an extended care
facility stay of more than 20 days.

Now, if a Medicare beneficiary has a hospi-
tal stay of more than 60 days, he will pay
$23 a day for the 61st through the 90th day,
up from the $21 per day charged in 1974. If
he has a post-hospital stay of over 20 days in
the extended care facility, he will pay $11.50
per day toward the cost of the 21st through
the 100th day, up from the $10.50 per day
charge in 1974.

If it becomes necessary for a beneficiary to
dip into his "lifetime reserve” of hospital
days, the extra 60 hospital days the bene-
ficiary can use when he needs more than 90
days of hospital care in any given benefit
period, the extra use will cost him $46 for
each reserved day, instead of the present $42
per day. □

Journal / January 1975 / Volume 68

MEDiCENTER PSYCHIATRIC
HOSPITAL

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Services Available

• Psychotherapy Individual and Group

• Chemotherapy

• Recreational Therapy
® Occupational Therapy

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• Neurological Consultation

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Therapeutic Community ap-
proach in an open setting.

Fully Accredi&ted

60 Beds

Mrs. Billie Speck-Administrator

® X-ray
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SPONSORED BYTHE OSMA

Washington National Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE
DISABILITY INCOME INSURANCE

Contact Association Counselors:

Phil Payne, Walter C. Wilson, C.L.U., ©r Rodman A. Prates

Administrators

720 NW 50th

PO Box 1 8593 405 842-3735 Oklahoma City 73118

Oklahoma State Medical Association

BEVERLY HILLS HOSPITAL
BEVERLY HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

PSYCHIATRY

Jackson H. Speegle, MD
John T. Holbrook, MD

PSYCHOLOGY

George R. Mount, PhD Tom I. Payton, MS

Donald L. Whaley, PhD Patrick R. Barnes, MS

Fred H. Jordan, MD
Joseph H. Lindsay, MD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND R.T. ACTING DIRECTOR

EDUCATION DIRECTOR

Jeanette Boothe

William E. Nix, PhD

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

Journal / February 1975 / Volume 68

news

Peer Review Foundation Publishes
Hospital Guidelines

In response to the new hospital Utilization
Review Regulations issued by HEW, the Okla-
homa Foundation for Peer Review has pub-
lished a set of Hospital Admission Guidelines
for distribution to all Oklahoma hospitals.

The guidelines cover the most common 106
hospital admitting diagnoses. It outlines the
criteria for admission under each diagnosis,
the usual length of stay in the hospital for the
diagnosis by age of patient, complications that
would cause extended stays, and a list of the
services that are usually rendered and those
that might be rendered for the diagnosis.

Publication of the manual became a crash
priority project of the foundation when the new
Utilization Review Regulations were released
by HEW. Published in the November 29th
issue of the Federal Register, the regulations
required hospitals to have an updated Utiliza-
tion Review function by February 1st, 1975.

The new regulations require that any elec-
tive or emergency admission for Medicare,
Medicaid, or Title V patient, must be certified
within one working day following the admis-
sion. The certification of the necessity for the
admission is to be based on written criteria and
standards to be selected by the physician
members of the hospital’s Utilization Review
Committee. Such standards are defined as
’professionally developed expressions of a
range of acceptable variations from a norm or
criterion. Norms are defined as numerical or
statistical measures of usually observed per-
formance.”

Realizing that most small hospitals do not
have the staff time or facilities to produce such
criteria and norms, the Oklahoma Foundation
for Peer Review took it upon itself to assist the
hospitals by furnishing criteria and norms that
had been researched and developed by the
foundation for possible use in a statewide
PSRO.

The foundation’s guidelines committee, over
the past several months, had studied criteria
and guidelines from Utah, Texas, Kentucky,
Ohio, and Mississippi. The committee recom-
mended that the Mississippi Guidelines be
used for the basis of guidelines in Oklahoma.
They were to be modified, somewhat, by the
inclusion of 'indications for discharge” of pa-
tients from the Kentucky and Ohio guidelines.

On January 12th the Board of Directors of
the Peer Review Foundation accepted the
recommendation of the guidelines committee
and ordered the OSMA staff to prepare and dis-
tribute the Guidelines Manual as soon as pos-
sible. Working in conjunction with the printing
department of the Oklahoma State Health De-
partment, a limited number of copies of the
manual were prepared for distribution.

Each manual contains a cross-index of diag-
nosis criteria, and explanation of how to use
the manual, and an explanation of how to mod-
ify the manual for peculiarities of a local situa-
tion or to add other diagnosis and criteria to it.

Due to the time limitations, only a limited
number of manuals were published. It is an-
ticipated that the manual will be published in
handbook form for distribution to all interested
persons in the near future. □

Society Named for Former Dean Bird

In recognition of his contributions to medical
education, the Robert Montgomery Bird Soci-
ety has been established to honor the former
dean of the Oklahoma College of Medicine.

Created by friends and alumni, the society
will sponsor a fund at the University of Okla-
homa Foundation, Inc., to be used for lectures,
visiting lecturers and support of teaching ac-
tivities pertinent to the College of Medicine. It
is anticipated that part of the funds will be
used to sponsor return visits to the school by
Doctor Bird.

Contributions may be sent to the Robert
Montgomery Bird Society, in care of Mr. Lee O.
Teague, Director, Development Office, Univer-
sity of Oklahoma Health Sciences Center, P. O.
Box 26901, Oklahoma City, Oklahoma 73190.

All gifts to the society are tax deductible,
and contributions are invited and welcome
from all physicians and lay persons.

In July, 1974, Doctor Bird resigned as dean
of the University of Oklahoma College of
Medicine, a post he had held since 1970. He
had been a member of the medical college
faculty for 22 years.

Doctor Bird left the College of Medicine to
become the director of the Lister Hill Institute
for Biomedical Communications in Bethesda,
Maryland. □

Oklahoma State Medical Association

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance
Springfield, Mass.

For additional details and application form, please contact

Phil Payne

Administrator

720 N. W. 50th Telephone 405 848-7661

P.O. Box 18593 Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

DOCTOR, WHAT WILL YOU EARN?

It depends, of course, on your age and annual earnings, but the amount can quite reasonably
exceed $400,000.

Is this logical? Not when you can participate in the. . .

O.S.M.A. GROUP DISABILITY INCOME PROGRAM

Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION
. . . gives you individual coverage at low group rates.

. . . offers flexible waiting periods at your option.

. . . guarantees you an income when you are disabled from an accident or sickness.

. . . offers optional Indemnity from $200.00 to $2,500.00 per month.

. . . pays for lifetime on accident and up to age 65 on sickness.

For Additional Information, call or write

Phil Payne, Jim Thaxton or Rodman A. Frates
C. L. FRATES & COMPANY, INC.

720 N.W. 50th P.O. Box 18695
OKLAHOMA CITY, OKLAHOMA 731 18
Telephone 405 848-7661

Journal / February 1975 / Volume 68

news

Legislative Reports
Available to Members

OSMA members may now receive the OSMA
Legislative Reporter. The Reporter is pub-
lished periodically throughout the Oklahoma
Legislative Session to keep physicians in-
formed on medical legislation.

David Bickham, Associate Executive Direc-
tor of the OSMA, edits the Reporter. It is au-
tomatically sent to all members of the medical
association’s Legislative Committee and to se-
lected physicians throughout the state. Any
physician wishing to receive the Reporter
should contact the association at 601 North-
west Expressway, Oklahoma City, Oklahoma
73118.

The first issue of the Reporter for 1975 was
published in mid-January.

It is anticipated that the 35th Legislature of
the State of Oklahoma will consider numerous
pieces of proposed legislation that could di-
rectly effect the practice of medicine. Each of
these proposed bills will be discussed in the
OSMA Legislative Reporter.

The association’s Legislative Committee has
already taken a position on several bills. They
voted to support bills that would waive the
physician-patient privilege under certain
circumstances, and one that would prohibit the
practice of acupuncture by other than licensed
physicians. They also went on record as sup-
porting bills that would require insurance
coverage for newborn infants, permit the
treatment of minors without parental consent,
and provide additional laboratory facilities for
the State Medical Examiner.

Other proposals discussed by the committee
included a state regulation on emergency med-
ical services, state subsidy of internship and
residency programs, and a medical review of
driver license applicants who have major phys-
ical impairments.

When the Legislature convened on Tuesday,
January 7th, there were 39 Democrats and
nine Republicans in the Senate and 76 Democ-
rats and 25 Republicans in the House of Rep-
resentatives. Interestingly enough, there will
be a majority of first- and second-term mem-
bers in the House of Representatives. Fifty-
seven members could be classified as
freshmen. □

Offering complete private Psy-
chiatric Services using the
Therapeutic Community ap-
proach in an open setting.

Fully Accrediated
60 Beds

Mrs. Billie Speck-Administrator

MEDiCENTER PSYCHIATRIC
HOSPITAL

1505 Eighth Wichita Falls, Texas 76301

Services Available

• Psychotherapy Individual and Group

• Chemotherapy

• Recreational Therapy

• Occupational Therapy

• Psychological Testing

® Psychiatric Social Worker Services

• Neurological Consultation
® Electro-Convulsive Therapy
9 Clinical Laboratory
« X-ray
® Pharmacy
9 Physical Therapy

• Medical Consultations

Oklahoma State Medical Association

“Disabled Physician” To Be
Subject of Conference

Alcoholism, drug dependence and mental
disorders existing in the physician population
will be the major theme of a national confer-
ence on the "Disabled Physician," April
11th- 12th, sponsored by the American Medical
Association.

A special invitation to attend the meeting
has been sent to all physicians by Malcolm C.
Todd, MD, AMA President. Meeting in the St.
Francis Hotel in San Francisco, the conference
will attract some 300 medical authorities rep-
resenting various specialties. Participants will
examine the motivational aspects, as well as
appropriate mechanisms, for encouraging doc-
tors with disabilities, to seek advice and
treatment.

Accented during this two-day meeting will
be accountability to the public through the as-
surance of competent patient care. Conference
speakers and attendees will focus on exploring
alternative formal and informal procedures for
the effective treatment, rehabilitation and dis-
ciplinary action, when necessary, of the dis-
abled physician.

The role of the medical society, relationships
with state licensing bodies and legislative sup-
port mechanisms will be other areas of discus-
sion.

Featured on the program are workshops on
treatment modalities, treatment facilities and
physician re-entry into professional life. The
AMA is sponsoring the conference through its
Department of Mental Health. The meeting it-
self is being hailed as a "milestone.”

In his letter of invitation, Doctor Todd said,
"alcoholism and drug addiction in physicians,
for example, often emerge as problems of
significant human tragedy in professional de-
vastation. Now is a critical point in medical
history for us to assume and exercise our full
responsibility in providing competent care to
patients. Accountability within the pro-
fession’s ranks and, more importantly, for the
public welfare has long been organized
medicine’s professional commitment as the
healers in society.”

The president also said, "organized
medicine, by virtue of its professional
commitment to the public welfare, must now
work toward developing a more viable strategy
of identifying and guiding those physicians
who have become disabled because of mental
disorders, alcoholism, or drug dependence.” □

Journal / February 1975 / Volume 68

Tutor Funds Needed For
Medical Students

Tutoring services are being made available
to first-year medical students at the University
of Oklahoma College of Medicine who might
desire, or be in need of them. The tutoring is
provided by upper-class students.

In the past, it was up to the individual stu-
dent to finance his own tutoring. Now, the Of-
fice of the Associate Dean for Medical Student
Affairs, would like to create a fund that would
be available for students who need tutoring.
Funds are being sought from physicians,
pharmaceutical manufacturers, service
organizations, local business people, and in-
terested laymen.

Funds for the tutoring service have already
been received from the Insurance Agency of
Cravens, Barnhill, Gilbert and Pellow; The
Jewish Woman’s Fund; Geigy Laboratories;
McNeill Laboratories; and the Searle Com-
pany.

Persons wishing to contribute funds should
direct them to the Office of the Associate Dean
for Medical Student Affairs, University of
Oklahoma Health Sciences Center, P. O. Box
26901, Oklahoma City, Oklahoma 73190. □

TECHNICONSMA 12/60

FOR SALE Technicon SMA 12/60, Se-
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pletely refurbished May, 1974. Serviced
January, 1975. Perfect working condition.
Best offer.

Sundra Brooksher

(405) 239-6106

Oklahoma City

news

DEATH

CHARLES J. ROBERTS, MD
1909—1974

Enid physician, Charles J. Roberts,
MD, 65, died on December 7th, 1974.
Born in Maywood, Illinois, Doctor
Roberts was graduated from North-
western University Medical School in
1935 and later that year established
his practice in Enid. He had long been
active in medical affairs, having served
as President of the Oklahoma State
Board of Medical Examiners and Pres-
ident of the Kingfisher County Medical
Society. He was a member of the
American College of Physicians. □

OSMA To Sponsor Hawaii
Tour in Fail

In conjunction with the American Medical
Association’s Clinical Session in Honolulu,
Hawaii, November 30th-December 5th, the
OSMA is sponsoring a ten-day trip for its
members.

The trip offers physicians the possibility of
combining swaying palms, grass skirts, sandy
beaches and continued medical education.

The first seven nights will be spent at the
beautiful Hawaiian Regent Hotel on Waikiki.
This will give physicians an opportunity to at-
tend either the scientific or business meetings
of the AMA’s Clinical Convention.

After the AMA Convention is over, two addi-
tional nights have been arranged at the magni-
ficent Maui Surf Hotel on the valley island of
Maui.

The per person price for the ten days is $595
in a deluxe room, or $575 in a superior room.
(For some reason, the "deluxe” is better than
the "superior” in Hawaii.)

A $75 per person deposit must accompany
reservation forms.

Over the next several months other tours
through the American Medical Association’s
Clinical Meeting will be announced. This one,
however, is the only one to be sponsored by the
OSMA. Additional information will be made
available in the near future.

The association has reserved the entire seat-
ing capacity of a Braniff Airline’s 747 aircraft.

While the trip is primarily arranged for
physicians, the arrangements that have been E
made by the OSMA will also accomodate any
non-physicians who may wish to accompany
the tour.

Reservations may be made by contacting the
OSMA at 601 Northwest Expressway, Okla-
homa City, Oklahoma 73118. □

Book List Available

In the December, 1974, issue of Postgraduate
Medicine, The Journal of Applied Medicine, is 1
a list of Books in Clinical Practice 1971-1975. I
A selected and annotated list for medical prac- t
titioners, indexed by subject and author, the 1
compilation has been prepared by Kelly M. (
West, MD, Professor of Medicine and of Con- i
tinuing Education, University of Oklahoma
Health Sciences Center; Ruth W. Wender,
MLS, Coordinator of Regional Library Ser-
vices, University of Oklahoma Health Sciences :
Center; and, Ruth S. May, MALS, Librarian ;
for the University of Oklahoma College of
Medicine Preceptorship Program.

Single free copies of the list are available
from the Office of Publications Management,
National Library of Medicine, 8600 Rockville
Pike, Bethesda, Maryland 20014, which sup-
ported, in part, the development of the tabula-
tion. □

CHANGE OF LECTURE DATE

Sixth Annual

MYRTLE LAUGHLIN
MEMORIAL LECTURE

HEMATOLOGY

NEW DATE:

Tuesday, February 25th, 1975, 4 p.m.

East Lecture Hall University of Oklahoma

Basic Sciences Building Health Sciences Center

Guest speaker, Aaron J. Marcus, MD,

Chief of the Hematology Section, New York
Veterans Administration Hospital, will speak on
“Current Concepts of Platelet Physiology.”

Oklahoma State Medical Association J

Book Review

Essentials of Clinical Endocrinology. By

Norman G. Schneeberg, MD, Clinical Pro-
fessor of Medicine (Endocrinology and
Metabolism). Hahnemann Medical College
and Hospital; Head, Section of Endocrinol-
ogy (Hahnemann), Philadelphia General
Hospital, Philadelphia, Pa. Clothbound, 449
pp. 210 illustrations and 2 color plates, St.
Louis: The C. V. Mosby Company, 1970.
$22.50.

This book came out of publication in August,
1970, and is being offered for review four years
later. Obviously it cannot possibly reflect the
tremendous strides in endocrinology and re-
lated disciplines that have occurred in the past
few years. Hence certain sections in the book
while reading correct in 1970 may appear
"off-beat” when viewed in terms of vintage
1974. For example, a brief statement on
"plasma sulfation factor” cannot justify the re-
surgent interests that have been generated
and exciting new data that have accumulated
in recent years on the somatomedins; and, the
now widely accepted Noonan’s syndrome is
still discussed under male Turner’s syndrome.

In fairness, the author has really succeeded
in putting together the vast store of knowledge
in endocrinology into a concise and very reada-
ble whole. This summation is especially ap-
preciated when one first reads the Preface. "No

attempt is made to compete with the several
available comprehensive endocrine text.” The
book succeeds in distilling endocrine knowl-
edge into a "presentable and digestible es-
sence” thereby easily reaching its intended
readers: students, residents and practicing
physicians. Even endocrinologists may have
occasion to use it to advantage such as in the
preparation of teaching slides.

Actually the book offers more. In addition to
strictly "clinical” endocrinology, basic under-
standing of endocrine physiology and
biochemistry is assured. The bibliography al-
though somewhat inconsistent in format (some
references contain titles, others do not), is well
selected and identifies significant reviews. The
tables and illustrations including photographs
and photomicrographs are well prepared or se-
lected and appropriately captioned. An appen-
dix of common abbreviations at the end of the
book helps the uninitiated easily understand
their meaning. The division of the book into
chapters, sections and subsections bolsters the
author’s simple style of writing making it
readable despite the limitations of scientific
discipline.

Again with the qualification that it is four
years old, the book could easily be recom-
mended for general medical reading but pri-
marily for the non-endocrinologist interested
in endocrinology. Cosme R. Cagas, MD □

INTERNAL MEDICINE REVIEW COURSE

East Lecture Hall, Basic Science Education Building
University of Oklahoma College of Medicine, Oklahoma City, Oklahoma

Developed by

The Department of Medicine, University of Oklahoma Health Sciences Center

and

Office of Continuing Medical Education for Physicians
Registration Fee; $15.00 per semester

Send Advance Registration to: Office of Continuing Medical Education for Physicians, University of
Oklahoma Health Sciences Center, P. O. Box 26901, Oklahoma City, Oklahoma 73190

DATE TITLE — SPEAKER

February 26, Infectious Disease I — Infectious Disease Section.

March 5, Infectious Disease II — Infectious Disease Section

March 12, Valvular Heart Disease — Eliot Schechter, MD

March 19, Gastroenterology I — Gastroenterology Section

March 26, Congenital Heart Disease In The Adult — Lofty L. Basta, MD

April 2, ASCVD and Cardiomyopathies — Stephen D. Shappell, MD

April 9, Gastroenterology II — Gastroenterology Section

April 16, Metabolic Disorders Presenting In The Adult — Sylvia Bottomley, MD

April 23, Pituitary Adrenalin and Endocrine Hypertension — David C. Kern, MD

April 30, Thyroids and Gonads — E. William Allen, MD

Journal / February 1975 / Volume 68

Miscellaneous Advertisements

OFFICE EQUIPMENT FOR SALE — 4200
National cash register posting machine appro-
priately coded for medical practice, used in
multispecialty group practice. Would be suit-
able for backup unit or spare parts. Also avail-
able, Edison central dictating unit, consisting of
13 separate phone units, two central receivers,
1 LP TV tape unit and two unit dictators. Will
sacrifice. Contact Jim Loy, Chickasha Clinic,
224-4853. □

MAKE YOUR PLANS NOW TO ATTEND

OKLAHOMA MEDICAL SUMMIT ’75

This combined meeting of the Oklahoma State Medical Association, the Ok-
lahoma City Clinical Society and the Oklahoma Academy of Family Physicians will
feature: Many scientific sessions; a Keg and Oyster Party; a Wine and Cheese
Tasting Party; Outstanding guest speakers; a Speaker’s Training Program; Inau-
gural Dinner-Dance featuring the Forrest Wasson Orchestra and many other educa-
tional and entertaining events.

April 24 - 26th, 1975 Lincoln Plaza Forum

Oklahoma City, Oklahoma

Oklahoma State Medical Association

fflfi

JOURNAL

auxiliary

Health Education — This new designation for
the former health careers chairman in medical
auxiliary better reflects the emphasis being
placed by the AMA, as well as the national
auxiliary. "It is a growing belief that any future
advances made in improving the nation’s
health will not result from spectacular bio-
medical breakthroughs. Rather, advances will
result from personally initiated actions that are
directly influenced by an individual’s health
related attitudes, values, beliefs and

knowledge Too few people understand

the close relationship between one’s health
status and one’s health behavior. By addressing
health problems at each grade level throughout
the school years, students are continuously en-
couraged to develop a life style that fosters good
health.” This statement from the AMA pamph-
let Why Health Education In Your School ?
concisely states the reasoning behind the aux-
iliary emphasis on Health Education. Accord-
ing to the President’s Committee on Health
Education, most major causes of death in this
country could be prevented if the American
public would change its smoking, drinking, eat-
ing and exercising habits. But, says the com-
mittee, little is being done in the schools toward
teaching children how to care for their bodies in
order to prevent disease. Because people have a
right to make choices about their health, health
education is of extreme importance. If they
make bad choices, then society pays the bill for
health care. Health Education is the only logic-
al answer — teach people to be responsible for
personal health care.

On a national level, legislation is pending in
H.R. 13084, the "Comprehensive School Health
Education Act,” with the endorsement of the
AMA. On the state level, in January, 1974, the
Oklahoma Legislature adopted a resolution "to

Journal / February 1975 / Volume 68

upgrade and improve the Health Education
Programs” recognizing "health education is the
basis upon which individuals make accurate
decisions concerning the availability of health
facilities and necessary health services and in
this way is the key to reducing the costs of
health care and improving the total health of
the people of the State of Oklahoma.” Is it not a
more desirable choice that tax monies be spent
on a positive approach aimed at changing in-
adequate health habits rather than on a
government funded health care program?

Mrs. Howard Liljestrand, national auxiliary
president, set our goals high when she said, "To
be champions of school curricula on effective
healthful living is certainly a project of great
magnitude, continuing need, and one that is
appropriate for us to adopt and shepherd. We
would make an immeasurable contribution to
America if we could stimulate full implementa-
tion of health education at the level of compre-
hension in each grade beginning with kinder-
garten.” The educators in the local school situa-
tions are in a dilemma as to how to meet curric-
ulum requirements with an ever-growing list of
subjects to be covered within the time limit of
school hours that we are accustomed to. They
are eager for help! Hopefully, auxiliary mem-
bers can provide some of that help, while recog-
nizing that schools have the responsibility for
health education. Of course, the opportunity to
serve on an advisory board with the department
of education at local, county or state level is a
most gratifying privilege. As resource people
who would be available even on a one-time
basis, auxiliary members would not only enrich
the curriculum studies, but enhance the image
of the physician’s wife in the local
community. — Sue Medcalf, Health Education
Chairman, Auxiliary to the OSMA □

xxxi

Guidelines for Hospital Care, a manual pub-
lished by the Oklahoma Foundation for Peer
Review, Inc., has now been sent to every Medi-
care certified hospital in the state. The manual
will assist smaller hospitals in complying with
the new Utilization Review Regulations that
went into effect February 1st. The manual was
published on a crash priority basis in a very
limited number. It is anticipated that after each
hospital has had an opportunity to review the
guidelines and use them for a period of time, the
guidelines will then be revised and published in
a more compact form for distribution to all
Oklahoma medical and osteopathic physicians.
OSMA’s Hawaii tour is filling rapidly. The
association is sponsoring a tour to Hawaii
November 30th-December 5th, during the
AMA’s Clinical Session in Honolulu. Informa-
tion was sent out in early January and over 50
reservations have already been received. The
tour features ten days and nine nights and in-
cludes round-trip jet economy fare from
Oklahoma City to Honolulu and a seven-night
stay in the Hawaii Regent Hotel in Waikiki.
There will then be an inter-island flight to Maui
after the AM A meeting with a two-night stay in
the magnificent Maui Surf Hotel. Price per per-
son (double occupancy of room) is $575 for a
superior room or $595 for a deluxe room in the
Hawaii Regent. This includes the air fare, bus
transfers, baggage handling tips, and the assis-
tance of an experienced tour director through-
out the tour. A $75 per person deposit must
accompany any reservation. Persons interested
should contact the Oklahoma State Medical As-
sociation, 601 Northwest Expressway,
Oklahoma City, Oklahoma 73118.

Although new National Health Insurance
proposals are being filed each week with Con-
gress, at least four congressmen feel that NHI
will not pass this year. A1 Ullman, (D-Oregon),
Chairman of the House Ways and Means Com-
mittee, told a recent meeting in Chicago that he
hoped that any NHI plan would build on the
present system. Paul G. Rogers (D-Florida),
Chairman of the House Sub-committee on
Health, predicted passage of an NHI bill by the
end of 1976 and said he was optimistic that free
enterprise would be retained. Two other mem-
bers of the House Ways and Means Committee,

Omar Burleson (D-Texas) and John J. Duncan
(R-Tennessee) expressed similar views. The
Chicago meeting was the AMA’s Annual Lead-
ership Conference for Medical Society Officers
and Executives.

Physician volunteers are being sought to

staff the OSMA’s First Aid Station in the Capi-
tol building during the months of April and
May. The station is open during the Legislative
Session, Monday through Thursday, and is
staffed by voluntary physician and registered
nurse. The station itself is well-equipped and
has an excellent stock of pharmaceutical
products. Any physician wishing to volunteer
should send his name and preferred dates to the
OSMA in Oklahoma City.

Doctors’ Wives Day at the Legislature, a pro-
gram sponsored each year by the OSMA
Woman’s Auxiliary, will be held March 5th.
The all-day meeting will start at 9:00 a.m. in
the Supreme Court Chambers on the 2nd Floor
of the State capitol building. The tentative pro-
gram calls for a welcome by Governor David
Boren, an explanation of the legislative process,
and then a panel discussion with four members
of the Oklahoma Legislature. Lunch will be
served at 12:00 p.m. in the OU Health Sciences
Center’s Faculty House. Guest luncheon
speaker will be Thomas Lynn, MD, acting Dean
of the OU Medical School. The afternoon will
be taken up with scheduled tours of the Health
Sciences Center. Ladies interested in attending
the meeting should contact the OSMA.

A revised health insurance claim form has
been published by the American Medical As-
sociation. It was designed as a single form that
would be acceptable to physicians and third
party payers for claiming and processing Medi-
care claims. The Bureau of Health Insurance
has stated that it will approve the use of the new
form in lieu of the existing SSA-1490 when
other major third party insurors in an area also
are willing to use it as their claims form.
Stumbling block to use of the form in Oklahoma
is the state law requirements for certain dis-
claimers to be included in all contracts on its
form in order to be in compliance with the law.
Until such time as the law can be changed, or
some alternative method worked out, it would
appear that the AMA’s form will not be accept-
able to Medicaid, and therefore not to Medicare.
In the meantime, the new form can be used for
health insurance companies. Copies of the form
may be obtained by writing the AMA, 535
North Dearborn Street, Chicago, Illinois

!■!

60610.

□

xxxii

Oklahoma State Medical Association

March
1975
68, No.

of th e Oklah oma State M edi cal As so ciati on

EDITORIAL BOARD

MARK R. JOHNSON, MD
Editor-in-Chief

HARRIS D. RILEY, Jr.,MD
Editor

ROBERT G. TOMPKINS, MD
Editor

ERNEST LACHMAN, MD
Corresponding Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

OFFICERS

JACK L. RICHARDSON, MD
President

ROGER J. REID, MD
Vice-President

HAVEN W. MANKIN, MD
Secretary-Treasurer

STAFF

DON BLAIR
BusinessManager

LOUISE MARTIN
EditcrrialAssistant

SUBSCRMTON TO THE JOURNAL is included in
membership fees. Other subscriptions are
$6.50 per year or $1.00 per copy with each
request subject to approval of the Editorial
Board.

POSTMASTERS: Send all change of address
notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

CONTENTS

special president’s page

The Malpractice Malady, Jack L. Richardson, MD . 63

special

Medical Malpractice Recent Developments in Okla-
homa, Joseph A. Sharp and Joseph F. Glass . 67

How To Be A Defendant, George F. Short and Nancy

C. Laughlin ....... 71

Malpractice : The National Situation, Ed Kelsay . 77

Physician Involvement in Workmen’s Compensation

Cases, Dick Lynn ...... 85

Professional Liability: The Oklahoma Situation, Ed

Kelsay ......... 88

News from the Oklahoma State Department of

Health ......... 91

news

Oklahoma Medical Summit To Be “Biggest and

Best” 92

New Address For Oklahoma Narcotics and Drugs

Commission ........ 93

National Malpractice Situation Deteriorating . . 95

Hawaii Tour In November Filling Rapidly . . 96

Utilization Review Regulations Stir Controversy and

Concern ........ 98

National Health Insurance Guidelines Issued By

AMA 100

Balkan Tour Combines Business and Pleasure . . 101

Health Benefits for the Unemployed . . . 101

St. John’s Hospital Offers Expanded Medical Educa-
tion Program ....... 102

Book Reviews ........ 103

Miscellaneous Advertisements ..... 103

Index To Advertisers ...... xxiv

Woman’s Auxiliary xxv

The Last Word xxvi

(Cover Art by William Cason)

Oklahoma State Medical Association

The Malpractice Malady

The frequence and the size of malpractice
awards have in recent years reached almost
crisis proportions. The time is long past due for
the recognition of this fact and there is serious
need for corrective action. Malpractice insur-
ance has become a nightmare to the insurance
carriers, an overwhelming burden to the prac-
titioners and a lottery prize to the willing pa-
tient and calculating attorney. Insurance com-
panies and doctors are both victims of the same
situation.

Physicians never have expected amnesty
from, absolution for, or minimization of actual
negligence or error. So long as medicine and
surgery are practiced by human beings there
will always be the possibility of error. As a mat-
ter of fact, judging from experience now had
with computers, it is quite apparent that there
will be less error by the human than by the
machine. Yet no profession or group of indi-
viduals has been so severely attacked and
penalized as have the doctors. This has led to a
very careful appraisal of how doctors should
attempt to avoid the problem, but far too few are
doing far too little about correcting unfair legal
aspects. Many have asked the medical profes-
sion to police itself to minimize unfortunate re-
sults but no one has ever proposed sufficient
regulations regarding lawyers’ activities in
pressing unfair claims.

The legal profession, just as the medical pro-
fession, consists for the most part of respected
and honorable constituents; however, both pro-
fessions have some venal, unscrupulous mem-
bers.

In our neighboring nation of Canada, the
medical and legal professions are not faced with
the morass of constricting laws and their
interpretations that we contend with in the US.
Legal work on a contingency basis is illegal and
unethical. The Doctrine of Res ipsa loquitur is
not applicable. Malpractice cases are tried by
judges and not juries and damages for pain and

Journal / March 1975 / Volume 68

suffering are not allowed. Compassion is not so
likely to replace logic and fairness.

The finest possible ongoing education will not
eliminate all mistakes, because no physician is
perfect. When such an imperfection becomes
manifest in the care of a patient, is it right that
a patient’s situation be compensated only by a
malpractice suit against the physician? Instead
of such a rationale a more equitable solution
would be provided by participation of the pa-
tient in an insurance plan that would protect
both patient and physician.

It is a foregone conclusion that constant vigi-
lance by the medical profession must be had for
the prevention of repetition of mistakes and
dangerous practices and to avoid educational
obsolescence. Peer Review is a must to provide
high quality care. On the other hand, pro-
fessional and economic assassination are rarely
justified.

CAUSES

One of the greatest causes of the problem is
the contingency fee of large size that has been
permitted the claimant’s attorney. This has in
many areas amounted to 50% of the award and
in hardly any instance has it been less than 33%
of the award. The attorney then is no longer a
counselor or representative of the claimant, nor
is he even just an advocate, but becomes a part-
ner of the claimant and even a proprietor of the
lawsuit. This results in an incentive from the
monetary standpoint that is too great for the
mortal barrister to resist and the attack be-
comes something more than vigorous. The law-
suit becomes not only an attack, but soon an
harassment and, finally, a vendetta. As a result
of the implications, innuendoes and actual
accusations, the result is often a punitive ver-
dict of exorbitant size far out of proportion to the
merits of the case. This triggers off other cases
for financial gain.

It is easy to see that this results in a
discrimination against doctors and their in-

Malpractice / RICHARDSON

surors, because the awards for the same dis-
abilities when sustained under medical circum-
stances are much greater than awards for the
same disabilities sustained from other causes.
For instance, the family of a pedestrian who is
killed by a dumptruck seldom receives as large
an award as does the patient who dies on the
operating table. The commercial driver, in
charge of brakes, speed, gear and overload — as
much the legal "captain of his ship” as any
operating surgeon — may very well have come
barreling down a hill. The complexion of un-
avoidable "accident” is put on the event and,
unless the driver is under some undue influence
such as drugs, he is rewarded with a trivial
citation for "improper maintenance,” "speed-
ing,” or "following too closely.” The civil
liabilities, however, are isolated for convenient
assault in a second person, some distance away,
the owner of the vehicle, and the recoverable
damages are limited to the size of his insurance,
if any.

In the case of the physician the tort and the
civil liability exist in the same person covered
necessarily by enormous insurance.

The commercial driver is up to his neck in
immunity, protected by the political power of
the trucking industry, the insurance industry
and the mythical nature of highway "safety” or
"mechanical failure.” The physician, contrari-
wise, is up to his neck in liability, surrounded by
Res ipsa loquitur, the flexible doctrines of dili-
gence and reliance, the imminent doctrine of
infallibility and a ready accessibility of the as-
sets. The case is readily documented. It is more
profitable to leave negligence law in the dark
ages and to see that nothing effective is done to
reduce slaughter on the highway.

It is obvious that part of the problem is due to
case-building and witnesses can always be ob-
tained for a proper price, much of the testimony
being a gross mishandling of the truth.

Another problem is the assumption that a bad
result is prima facie evidence of malpractice
unless a doctor can prove himself innocent, this
being the exact opposite of the assumption held
in all other legal matters. One California judge,
surprisingly enough, has gone so far as to state
that, regardless of the facts in the case, the
doctor and his insurance company are the only
ones capable of meeting the financial require-
ments of the claimant and therefore the award
should be made for the claimant and against the

doctor! This ridiculous twist of logic and juris-
prudence should have no place in our American
society, let alone exist in our courts of law.

Much has been said and written to the effect
that a major cause of legal action against the
doctors is due to a decrease in the consideration
of the doctor for the patient. This simply is not
so. Most assuredly the horse and buggy doctor
no longer exists, but today the patient would not
want such a physician. In past years the doctor
could offer little more than his mere presence
and personal attention. The modern doctor,
though much busier, has no less a consideration
for, and sense of obligation to, those in his care.
The pressure of his work is reflected in the high
incidence of mortality from heart disease in
members of the medical profession. The modem
doctor is very well aware of his duty. His prac-
tice and the success of it are dependent upon the
satisfaction of his patients and he deeply re-
sents anything that interferes with the mutual
trust that should exist between them.

EFFECTS

1. Some doctors are avoiding high risk cases.

2. Some doctors are accepting early retire-
ment to avoid high insurance premiums and
malpractice action.

3. Ultimate reduction in doctor availability
to the public will occur.

4. Lessening of confidence of the patient in
the doctor, or conversely of the doctor’s faith in
the patient, thus creating a mutual breach un-
necessarily. Harmonious interpersonal rela-
tionships and trust are necessary for the most
effective health care.

5. Decrease in medical progress and de-
velopment of new techniques and methods by
stifling the use of certain heroic and original
measures that might very well be more effec-
tive.

6. Decrease of interest by prospective medi-
cal students in the practice of medicine and
surgery.

7. Increased cost of medical care to all by the
necessity of practicing "defensive medicine,”
with a super-abundance of tests, x-rays, re-
ports and legal advice.

8. Interference with sound surgical judgment
occurs. Doctors have lost legal cases when sur-
gery was withheld as well as when they have
operated and a bad result ensued.

9. Malpractice insurance rates are becoming
prohibitive and in some cases insurance not
available at all. Between 1960 and 1970 liabil-
ity insurance premiums for all physicians in-

Oklahoma State Medical Association

creased 539% and for surgeons skyrocketed
951%.

REMEDIES

1. Eliminate the contingency fee. Both
claimants attorneys and defense attorneys not
only evince little interest in this recommenda-
tion, but also seem to become a little frantic
when it is mentioned. Perhaps they like the
adversary system to remain status quo. They
should be reminded, however, that a conting-
ency fee has been outlawed in every other
English-speaking country in the world and in
all European countries on the continent with
the exception of Spain. It produces excessive
incentive to file a lawsuit. Under the present
system it costs the unhappy patient nothing to
sue; human frailty cannot resist such a temp-
tation. Some have said this amounts to a "free
roll of the dice.”

The time-worn contention that the con-
tingency fee allows the poor man to be rep-
resented is shallow indeed. If the compassion of
our legal friends is actually that great, why do
they walk away with such a large part of the
award — 33% to 50% ?

There is a better method in which the attor-
neys can represent their clients and still be
remunerated. It will be a simple matter to es-
tablish rotating panels of attorneys willing to
handle such cases for proper fees and these
panels could be established by the courts. It is
interesting to note that the attorneys have
such panels acting as Legal Aid Societies
wherein such cases as divorces and small
claims can be handled. Public defenders are
even available to murderers. On the other
hand, it is obvious that a client never seems to
have any difficulty in finding representation
when a malpractice case is in the offing, since
the reward may be much greater. A govern-
ment legal program for the poor could be estab-
lished; this would be no less logical than a gov-
ernment medical program.

To correct the contingency fee problem will
obviously be quite difficult, due to formidable
political and constitutional barriers set up by
plaintiffs lawyers, many of whom are in state
legislatures. Nevertheless the fact that this
situation exists only in the United States
should tell them that it is long past due that
this matter be corrected.

2. Establish through courts the maximum
attorney’s fee that is practical and judicious in
each case and allow this knowledge to be
known to a jury before its deliberation, just as

medical fees are revealed. Doctors are often
asked on the witness stand to disclose their
charges both for treatment and for testimony
and it would seem only logical that the attor-
ney should declare his possible financial gain
from representing his client.

3. Remove discriminatory and punitive
awards against physicians. Awards have now
exceeded $4 million. This obviously is partly
due to an attempt to be punitive in rendering
such a verdict and yet it should be apparent
that no physician would desire the occurrence
of a bad result. Not only does it harm his prac-
tice and assault his pride, but it may very well
render his family and himself bankrupt. The
entire malpractice litigation experience is
traumatic, expensive and time-consuming to
any doctor.

4. Eliminate abusive treatment of the doctor
witness or defendant as well as all others giv-
ing testimony. This has been effected in most
other countries.

5. Eliminate inflammatory evidence such as
bringing into the courtroom the amputated ex-
tremity in a brown butchers paper and proceed
to draw an analogy. This has also been elimi-
nated in other civilized countries.

6. Insist that the plaintiff, in event that the
case has no merit and the court rules against
him, be made to pay the court costs and fees of
the defense attorney. This is done in Great
Britain, Canada, Australia, New Zealand and
elsewhere. It will help to diminish nuisance
suits filed simply to extort a settlement.

7. Eliminate the splitting of fees among at-
torneys. This practice has been outlawed in the
medical profession long ago. Actually, though
apparently unknown and unobserved by many
attorneys, it is also forbidden by Canon 34 of
the American Bar Association when the refer-
ring attorney has no active participation with
the case or responsibility for it. Some attorneys
who do not care to soil their hands by an unjust
malpractice case are not above referring it to
someone who will and then, though remaining
in the background, share in the profits. This
increases the frequency of malpractice suits
and many are filed that have no merit. Up to
now the plaintiffs attorney has never been
seen to list his fee on the well known courtroom
blackboard.

8. Reduce the application of Res ipsa loquitur
to the obvious, as it once was. Many complica-
tions are simply not explainable. The burden of
proof should be on the plaintiff, as in other

Journal / March 1975 / Volume 68

Malpractice / RICHARDSON

legal matters. To infer negligence is frequently
unjust.

9. Return to the acknowledgement that the
doctor should be considered innocent until
proven guilty.

10. Emphasize that a bad result does not in
itself indicate malpractice and that certain oc-
currences or accidents are unavoidable. Perfect
results are not the rule.

11. Consider the development of "medical ac-
cident insurance,” "professional casualty in-
surance,” or "maloccurrence insurance”
whereby the victim may be compensated a
reasonable amount without wrongdoing being
proved and without indictment of the doctor, as
in auto accidents and other types of casualties
and catastrophies.

It should perhaps be pointed out that "no
fault” insurance would not be a practical solu-
tion. This would simply result in a large vol-
ume of small claims and great expense without
eliminating the large claims already occur-
ring.

12. Utilize a panel of impartial experts to
determine the degree of disability, thus allow-
ing the monetary amount to be determined by
an informed court. In a somewhat similar fash-
ion, utilization of arbitration committees of in-
formed individuals could be established along
the lines of industrial courts. Compensation
there is provided regardless of fault.

13. Establish a limit of recovery, perhaps
some such figure as $50,000, with legal fees
based on time and effort expended and not to
exceed fees for other civil action; or, at least, do
as New Jersey has done and by law effect a
decreasing scale of legal fees as the size of the
awards increase, this referring to the percent-
age of the award.

14. Allow insurors to make advance pay-
ments to plaintiffs for medical care and other
expenses before the issue of liability is re-
solved. This could improve the emotional cli-
mate in serious injury cases.

15. Permit either side to request a pre-
liminary trial on whether the statute of limita-
tions has expired before the substance of the
suit is tried.

16. Possibly consider that all individuals
carry insurance of their own for unfortunate
results. If each individual in the United States
paid one dollar a year, this would result in a
fund of over $200 million, much more than

has been spent in recent years in malprac-
tice action. As the matter now stands, 200,000
doctors, 0.1% of the population, are carrying
insurance for a population of 200 million.
Very possibly the federal government will
someday step in. Senator Ribicoff and his com-
mittee have recognized the seriousness of the
situation. Most assuredly legal fees would
then be controlled.

17. Develop an assigned risk pool for doctors
in vulnerable practices.

18. Lastly consider becoming "suit-proof’ by
transferring all funds to wife or by other legal
procedure.

The time is long past due for a complete re-
view of this serious problem and for logical cor-
rections to be effected. Progress will require
the cooperation of the more high-minded of the
legal profession.

During the past few years an award was
made in the Florida court to a patient for
$1,800,000 and the attorney had a 40%
(contingency fee) contract. This amounts to
$720,000. There is no way to justify such a fee.
Obviously the case was presented to the jury
with figures designed to prove the $1,800,000
was due the patient for pain, suffering and
medical expenses. Yet the attorney walked
away with 40% of it! So who was lacking in
compassion?

A very interesting thing happened when the
award was declared — the claimant’s attorney
fainted. Now it is a well known fact that a
healthy individual usually faints because of
fear, surprise or pain. It is pretty apparent the
lawyer was surprised; surely it was not from
fear or pain.

In past years our various medical organiza-
tions have demonstrated very little effect in
correcting the very unfair results of malprac-
tice actions. All too much timidity is shown in
facing up to the legal profession and legis-
lators, the unfair jeopardy resulting from the
contingency fee and the astronomical awards.
True enough, it will not be easy to get through
state legislatures corrective legislation. A na-
tional program of public information must be
mounted. Certainly something must be wrong
in the present laws allowing contingency fees
when we are the only advanced country in the
world that permits it. When doctors find them-
selves without insurance coverage, the practice
of their profession will no longer be possible
and the public cannot be served. Jack L.
Richardson, MD □

Oklahoma State Medical Association

Medical Malpractice
Recent Developments in Oklahoma

JOSEPH A. SHARP
JOSEPH F. GLASS

The malpractice climate in any state is
established by the trends in its court system.
Recent decisions in Oklahoma courts
indicate that Oklahoma has a health
professional liability situation. This
article is a review of those recent
decisions and their impact.

Since 1972, the Supreme Court of the State
of Oklahoma has rendered several interesting
legal opinions concerning the area of medical
malpractice. The opinions concern themselves
primarily with the Doctrines of Res ipsa lo-
quitur, Informed Consent. It is the purpose of
this article to inform the medical profession of
the standards and attitude of the Supreme
Court of the State of Oklahoma, with respect to
the above doctrines in the area of medical mal-
practice.

In the case of Holland v. Stacy,1 the evidence
established that the plaintiff was hospitalized
for treatment of gangrenous toes. For five days
he was given substantial doses of an alcoholic

stimulant and another drug called "elixir of
Roniacol.” After several days, the plaintiff
complained that the medications were making
him nauseous. Near the end of the fifth day,
the patient became blind. His condition was
diagnosed as "retinal central arterial throm-
bosis.” An AMA publication on drugs stated
that the drugs administered to the plaintiff
could be harmful to patients with cerebral vas-
cular diseases. The defendant-physician ad-
mitted that he was aware that the plaintiff had
previously been hospitalized with a condition
diagnosed as "cerebral vascular lesion, type
unknown, but probably thrombosis.”

The trial court found that the Doctrine of Res
ipsa loquitur or presumed negligence did not
arise under these facts. To be hospitalized for
gangrenous toes and after five days of internal
medication to awaken blind is not such an
extraordinary event as to raise an inference of
negligence. For a plaintiff to apply the Doc-
trine of Res ipsa loquitur, the evidence must
establish "what thing caused the injury.” Here,
there was no evidence establishing that either
the alcoholic stimulant or the elixir of Roniacol
or a combination of the two caused the blind-
ness of the plaintiff-patient. Therefore, the
court rendered a judgment for the physician-
defendant.

In the case of Martin v. Stratton,2 the evi-
dence established that the plaintiff-patient en-
tered the hospital to have a tumor removed

Journal / March 1975 / Volume 68

Malpractice / SHARP, GLASS

from his hand. The defendant-physician ad-
ministered a brachial block anesthetic, by in-
jecting a hypodermic needle into the brachial
plexus area of plaintiffs right shoulder. The
patient felt two sharp pains in the shoulder
area and then lost consciousness. Following
the operation and after the numbness had sub-
sided, the plaintiff-patient suffered severe
pains in his shoulder for six weeks. Three years
later, he had not regained full use of his arm.
The evidence further established that the
plaintiff-patient suffered a partial loss of the
axillary nerve supply to the deltoid muscle. As
well as claiming the application of the Doctrine
of Res ipsa loquitur, the plaintiff also claimed
the lack of informed consent.

The defendant-physician’s evidence estab-
lished that there were possible causes of the
injury other than the administration of the
block. Other possibilities included positioning
of the arm during or after surgery or acts oc-
curring in the recovery room. The physician’s
evidence also showed that the proper adminis-
tration of the block causes a tingling feeling
along the nerve, down the arm, similar to that
of a mild electric shock. Therefore, the court
held that the Doctrine of Res ipsa loquitur was
not applicable since it was not established by
the evidence "what thing caused the injury.”
Insofar as the plaintiff-patient’s claim of a lack
of informed consent, the court indicated that if
the theory of informed consent was ever
adopted by this state, the plaintiff must show
that the defendant-physician failed to disclose
what a reasonably prudent physician in the
medical community in the exercise of reasona-
ble care would disclose to his patient, or that
there existed material risks which were inher-
ent in the proposed medical procedure in the
terms of seriousness, probability of occurrence
and feasibility of alternatives, and the
defendant-physician failed to disclose these
risks to the plaintiff.

The court found that there was no evidence
from which a jury could have reasonably in-
ferred that material risks, in terms of prob-
ability and seriousness of consequence, were
inherent in the administration of the anesthe-
tic. Neither was there evidence to establish
that the probability of an injury such as the
plaintiffs was of such magnitude that a patient
deciding whether to submit to the procedure
should be warned of the possibility. The evi-

dence indicated that this type of injury result-
ing from such an injection was extremely rare.
Therefore, the Supreme Court affirmed the
lower court’s decision in holding for the physi-
cian.

In Murray v. Vandevander ,3 the plaintiff
sued the defendant-physician for loss of con-
sortium and the right to produce another child.
The evidence showed that the defendant-
physician performed a hysterectomy upon the
plaintiff s wife without the plaintiffs consent.
The defendant-physician had obtained the con-
sent to perform the operation from the
plaintiffs wife. Before the surgery, the plain-
tiff warned and specifically notified the
defendant-physician that he strenuously ob-
jected to the surgery being performed on his
wife.

The court held that the choice of whether a
woman will or will not bear any more children
is strictly her decision, and the consent of the
husband is not necessary.

In a 1973 case Karriman v. Orthopedic
Clinic, 4 the plaintiff-patient sued the
defendant-physician for a breach of warranty
and a lack of informed consent. The evidence
established that the plaintiff had been having
back trouble and other related problems for
approximately a year. The defendant initiated
conservative treatment which did not improve
the patient’s condition. Thereafter surgery was
recommended and performed. Complications
developed and a second surgery was performed.
Additional complications developed, including
numbness and abnormality in the genital area
and "dropped feet.” The plaintiff-patient
claimed that the defendant warranted a cure
through surgery and did not inform him of the
possible severe complications that could result
from surgery. There was a sharp difference in
the testimony of the plaintiff and defendant as
to what assurances were made.

The court quoted verbatim the following
"Consent to Operation” taken and signed by
the plaintiff:

I hereby authorize Dr. ( name of doctor
or doctors performing the operation ) and
whomever he may designate as his assis-
tants to perform upon myself (State name
of patient or ’myself) (To be filled in by
patient) the following operation (Here the
November 13th Consent stated, among
other things: r Laminectomy & disc re-
moval, . . Here the November 16th
Consent stated: Reexploration of lumbar

Oklahoma State Medical Association

region and possible Laminectomy ’;) and if
any unforseen conditions arise in the
course of the operation calling in his
judgment for procedures in addition to or
different from those now contemplated, I
further request and authorize him to do
whatever he deems advisable.

The nature and purpose of the opera-
tion, possible alternative methods of
treatment, the risk involved, and the pos-
sibility of complications have been fully
explained to me. I acknowledge that no
guarantee or assurance has been made as
to the results that may be obtained.

I consent to the disposal of tissues, to
photographs of operative parts, and ad-
mission of necessary personnel into the
operating room, or persons deemed neces-
sary by attending surgeon. I certify that I
have read fully and understand above
consent to operation; that the explana-
tions therein referred to were made, and
that all blanks or statements requiring
insertion or completion were filled in and
inapplicable paragraphs, if any, were
stricken before I signed.

Witness(s): Amelia Stark Signed Joseph
Karriman, Jr.

The plaintiff testified that he did not read
the consent form because of what the doctor
had told him. The court stated:

While he and his wife testified to
statements made by Dr. M to them, that
might be interpreted as having painted
an optimistic picture of the possibility of

Joseph A. Sharp, LLB, received his degree
from the University of Oklahoma. Mr. Sharp
is a Past-President of the Oklahoma Asso-
ciation of Defense Counsel, a member of the
Federation of Insurance Counsel and the Order
of Coif. He is a partner in the firm of Best,
Sharp, Thomas, Glass and Warner of Tulsa,
Oklahoma.

A partner in the firm of Best, Sharp, Thomas,
Glass and Warner, Tulsa, Oklahoma, Joseph F.
Glass received his LLB degree from the Univer-
sity of Oklahoma. He is a Past-President of
the Insurance Section of the Oklahoma Bar
Association and the OSMA-OBA Medical-
Legal^Relations Committee and a member
of the International Association of Insurance
Counsel.

the disc protrusion’s removal alleviating
plaintiffs problems, or at least not worse-
ning them, and we question the admissi-
bility of such parol evidence to contradict
the statements in the above quoted writ-
ings . . .

The court further found that it was no excuse
that the plaintiff did not read the consent form.

The "Consent to Operation” set forth above
is an extremely well drawn instrument and its
use is highly recommended to all doctors who
perform any surgical procedure since it covers
almost every possible eventuality.

As to the breach of warranty claimed by the
plaintiff-patient, the court held that the physi-
cian is not responsible for damages for want of
success, unless it is shown to be a result of a
want of ordinary skill and learning, such as
ordinarily possessed by others of his profession.
Therefore, the Supreme Court affirmed the
judgment for the defendants.

In a 1973 case Runyon v. Reid,5 an action of
malpractice was brought by the decedent’s
widow against a psychiatrist, a general prac-
titioner, a mental health foundation and a
pharmacist as a result of an overdose of sleep-
ing pills. The evidence established that the de-
cedent suffered from a serious emotional disor-
der, and had been admitted to the hospital for
the mentally ill on three occasions in the years
of 1945, 1947, and 1956. The second hospitali-
zation occurred after an attempted suicide. A
year after his last hospitalization, the decedent
became a patient at an outpatient clinic
owned by the defendant foundation. In 1963,
the decedent’s condition became more severe
and he was referred to the defendant-
psychiatrist. The psychiatrist continued to
treat the decedent and diagnosed the condition
as schizophrenia. The psychiatrist did not re-
gard the decedent as suicidal in nature. From
1959 until the patient’s suicide, the general
practitioner treated the decedent for various
physical ailments. The foundation, psychiat-
rist and general practitioner all had prescribed
drugs for the decedent. The general prac-
titioner had prescribed Carbrital for the dece-
dent on several occasions. The defendant-
pharmacist had filled several of the prescrip-
tions for the decedent. However, on the date
before the suicide, the decedent refilled the
prescription for Carbrital without the approval
of the prescribing physician. Thereafter, the
decedent committed suicide by an overdose of
Carbrital.

Journal / March 1975 / Volume 68

Malpractice / SHARP, GLASS

The court in holding for the defendants,
made several observations which will interest
the medical society. First, where neither men-
tal health foundation, psychiatrist nor general
practitioners prescribed the particular sleeping
pills, which the decedent used to voluntarily
commit suicide, and there was no indication
that the decedent was suicidal in nature, they
were not liable for the decedent’s death. Sec-
ond, with respect to the pharmacist, the court
made some interesting observations. The
pharmacist who refills non-refillable drug pre-
scriptions without a physician’s permission,
should not in all circumstances, be liable for
the death of the purchaser who uses the drug so
obtained to commit suicide. The statute which
prohibits the druggist from refilling prescrip-
tions without the physician’s permission does
not impose an affirmative duty upon the
pharmacist to protect his customer from the
customer’s voluntary act of suicide. Further,
the court stated that where the decedent wil-
fully committed suicide by taking an overdose
of a prescription drug, knowing the physical

effect of his act, such action constituted an in-
dependent, intervening cause and the
pharmacist’s negligence in refilling the pre-
scription without the physician’s permission
was not the proximate cause of the decedent’s
death.

The authors feel that the members of the
medical profession should be encouraged by
these recent opinions. The trial courts backed
by the Oklahoma Supreme Court are requiring
strict proof of negligence in most medical mal-
practice cases. The courts are not allowing a
presumption of negligence to arise just because
a patient does not get well. We feel that our
Supreme Court is taking a fair and moderate
approach to the extremely serious problem of
medical malpractice litigation and that those
reported cases will discourage the filing of such
questionable cases in the future. □

References

1. Holland v. Stacy, 496 P. 2d 1180 (May 2, 1972).

2. Martin v. Stratton, 515 P. 2d 1366 (October 23, 1973).

3. Murray v. Vandevander, 522 P. 2d 302 (April 16, 1974).

4. Karriman v. Orthopedic Clinic, 516 P. 2d 534 (Nov. 20, 1973).

5. Runyon v. Reid, 510 P. 2d 943 (March 13, 1973).

200 Franklin Building, Tulsa Oklahoma 74103

CERTIFICATION EXAMINATION

for

AMERICAN BOARD OF FAMILY PRACTICE

The American Board of Family Practice announces that it will give its next
two-day written certification examination on November 1st-2nd, 1975. It will be held
at five centers geographically distributed throughout the United States. Information
regarding the examination may be obtained by writing:

Nicholas J. Pisacano, MD, Secretary
American Board of Family Practice, Inc.

University of Kentucky Medical Center
Annex No. 2, Room 229
Lexington, Kentucky 40506

Please Note: It is necessary for each physician desiring to take the examina-
tion to file a completed application with the Board office. Deadline for receipt of
applications in this office is June 15th, 1975.

Oklahoma State Medical Association

How To Be A Defendant

GEORGE F. SHORT
NANCY C. LAUGHLIN

A malpractice lawsuit can be a traumatic
experience to a physician. Current
figures indicate that one out of every six
physicians in Oklahoma will be sued at some
time during his professional career. In
this article two knowledgeable
attorneys discuss ways a physician can
avoid such suits and then what he
should expect in the unfortunate event
that he becomes embroiled in one.

Not so many years ago, a physician in Okla-
homa could expect to practice throughout his
professional life without so much as the threat
of a malpractice claim, much less the filing of
an actual suit. In all probability, this was not
particularly the result of the lay person’s or the
patient’s understanding of the problems con-
fronting the physician in his diagnosis and
treatment of the patient; it was more the result
of a feeling of closeness and respect for the
physician on the part of the patient, coupled
with the reluctance of lawyers to file such
suits.

Formerly, most trial lawyers who customar-
ily represented plaintiffs, or the persons mak-
ing claims, made their "bread and butter” from
the litigation of automobile accidents. In order
to increase the amount of their client’s dam-
ages, it was necessary that they have tes-
timony from physicians to say that the client
had indeed suffered substantial injuries result-
ing from the accident, and therefore they were
reluctant to antagonize the medical profession
by the filing of malpractice lawsuits. However,
it has become evident that some form of no-
fault insurance will soon be in effect in all
states. The provisions of this type of insurance
create a situation in which personal injuries
arising out of automobile accidents will not be
litigated unless the injuries are both perma-

nent and substantial, so substantial that they
will be obvious to a jury without embellish-
ment by a friendly expert witness, a physician.

At the same time, the personal feelings for-
merly had by the patient for his or her physi-
cian have been diminished by two things:
First, the increasing importance of the
specialist, who often does not see the patient
until a crisis has developed, and secondly, the
increasing transience of the population, which
decreases the patient-physician contact and
the development of a patient-physician rela-
tionship. Thus, the malpractice claim and the
malpractice lawsuit have suddenly prolifer-
ated in an almost unbelievable fashion, due to
sociological factors which have no bearing
whatsoever on the actual quality of care ren-
dered to the patient.

Physicians of national standing and impec-
cable credentials now find themselves with not
one, but two or even several pending malprac-
tice claims or filed lawsuits, and whether the
patient’s claims are eventually handled
through government intervention or any other
means, any realistic physician who embarks on
the practice of medicine must be prepared for
the fact that at some point in his professional
life, his professional competence with regard to
the handling of a given patient will be ques-
tioned, and compensation will be sought by
that patient for a less than perfect post-
treatment result.

At present, the physician or his insurer is
required to compensate the patient for an un-
desirable result only where legal fault on the
part of the physician — a "departure from the
standards of medical practice in the commun-
ity” — can be established in court by expert
testimony. It is, therefore, part of every
physician’s professional education to be cog-
nizant of our present system of deciding such
claims, of those practices which should be
avoided in order to avert the malpractice
claim, and, perhaps more importantly, since a
claim may arise even when the physician has
rendered the best of treatment to the patient,

Journal / March 1975 / Volume 68

A Defendant / SHORT, LAUGHLIN

to know how to conduct himself most effec-
tively when a claim arises.

WHAT CAUSES A MALPRACTICE SUIT?

The law gives a physician a rather realistic
latitude in defining what constitutes actual
negligence. The mere fact that a physician may
have made a mistake in diagnosis or in the
selection of treatment does not mean that the
physician was negligent. The law recognizes
that, even within the bounds of what is legally
termed as "the standard of the community” a
physician is not omniscient; for example, a
physician is never held to the standard of what
would have been the appropriate treatment in
light of subsequent developments, unless those
subsequent developments should have been
foreseeable to the physician at the time he se-
lected the treatment. This does not prevent pa-
tients from filing malpractice claims whenever
they are confronted with the natural progress
of their own disease process, or with any result
of treatment which they consider undesirable.

As lawyers defending malpractice claims, we
see many motives for the filing of such lawsuits
aside from an actual feeling on the part of the
patient that the doctor was negligent. Some
motives predominate; often, a parent or other
family member feels guilt at not seeking medi-
cal help soon enough, or for some other per-
sonal reason, and this guilt can, for obvious
reasons, be alleviated by placing the blame on
the physician. The housewife who is getting no
attention, or whose husband has lost interest
in her, finds a sense of importance in
righteously pressing her claim against a physi-
cian, and an amazing number of these women
claim that sexual relations with their hus-
bands are painful when, in fact, there could be
no possible relationship between their illness
and complication, and their ability to enjoy a
full sexual life. Likewise, we see the male, who,
having lost interest sexually in his wife, is
eager to characterize himself as having been
rendered impotent by the surgeon who per-
formed a transurethral resection, despite the
fact that there is no known physical cause for
impotence following such procedure. Finally,
there is the patient who simply develops a dis-
like for the physician, often for reasons totally
unrelated to the quality of medical care;
perhaps the doctor spoke too bluntly to the pa-
tient or a member of his family, or perhaps the

physician, albeit unrelated to the necessity of
caring for the patient adequately, was not
present on some occasion when the patient
needed or desired emotional support.

It is important for the physician to keep in
mind that, should he be sued, his attorneys are
probably aware of these collateral motives, and
that he as a physician need not waste time
convincing his attorneys that he did in fact
render excellent care to the patient. Likewise,
the physician who has been sued should not
feel that his competence is in question, in light
of the many reasons that lawsuits of this type
are filed, totally aside from any failure in pro-
fessional treatment by the physician.

WHEN SUIT IS FILED

Although most insurance policies require
you to report potential claims to your insur-
ance company even before a lawsuit is filed,
you will probably not come into contact with
the defending lawyers until the Petition and
Summons are served upon you. Whatever
events have preceded the filing of a petition
cannot be altered, but the conduct of the physi-
cian in relation to his attorneys can be of ut-
most importance.

More than one lawsuit has been settled
where no possible negligence on the part of the
physician could be determined by the lawyers,
simply because the physician was so difficult to
deal with in terms of preparing him to be a
witness in his own behalf. Most professional
liability policies carry a cooperation clause,
which stipulates that liability coverage will be
extinguished should the insured fail to cooper-
ate with the insurance company or the lawyers
hired to defend the physician. As a practical
matter, no matter how difficult to deal with the
physician may make himself, coverage is
rarely destroyed on this basis, but the
physician’s attitude toward his insurance com-
pany and his lawyers has an untold effect on
the amount of settlement which the lawyers
are willing to recommend as opposed to the
prospect of going to trial.

First of all, it is well to keep in mind that,
since your insurance company as a writer of
company malpractice coverage, probably has a
great number of such policies, the lawyers
which they have employed to protect your in-
terests are probably thoroughly familiar with
the malpractice claim. In a sense, they are
specialists, just as is the physician who has
gone through a residency and who restricts his

Oklahoma State Medical Association

practice to a particular area of medicine. Not
only are these attorneys thoroughly familiar
with the problems of malpractice litigation,
but they are thoroughly familiar with the prob-
lems you face as a physician, and the tremend-
ous value of your time. Nonetheless, it is im-
perative that they make certain demands upon
your time in order to properly defend you and
protect your interests. If they are familiar with
the problems of a physician, they will try to
schedule all time required of you in the man-
ner most convenient to the demands upon your
time by your professional practice. However,
they may be required by actions on the part of
the lawyers on the other side to be present sud-
denly at the pre-trial testimony, by deposition,
of certain witnesses. Before attending the de-
positions of these witnesses, they might desp-
erately need to confer with you on short notice;
it is always in the best interest of the physician
to make himself available for such conferences,
even though it may be inconvenient, and to
realize that this is not a whim of your own
attorney, but rather a matter of circumstantial
pressure exerted by the other side.

One of the most frequent tasks which the
defendant physician is first required to per-
form is the answering of interrogatories. These
are questions which are made up by the
plaintiffs attorney and served upon the defen-
dant physician. They are not the creation of the
physician’s attorney, nor is there anything
which your attorney can do to avoid the an-
swering of such questions. The answers must
be returned to the plaintiff in writing within a

George F. Short received his LLB degree from
the University of Oklahoma in 1950. He is pres-
ently associated with the firm of Pierce, Couch,
Hendrickson and Short in Oklahoma City. His
professional affiliations include the Oklahoma
Bar Association, the American Bar Association,
the International Association of Insurance
Counsel, the Trial Attorneys of America, the
Oklahoma County Legal Aid Society, and the
Oklahoma City Jury Trial Lawyers Associa-
tion.

In 1973, Nancy C. Laughlin, JD, received
her degree from the University of Oklahoma.
She is a member of the Oklahoma Bar Associa-
tion, the American Bar Association, the Okla-
homa Association of Defense Counsel, and the
Oklahoma City Jury Trial Lawyers Associa-
tion.

limited time period, and the answers are under
oath. They may be used in trial of the lawsuit
to cross-examine you as the defendant, and are
therefore of great importance. It is therefore
necessary that they be answered accurately
and completely, and this is often a burdensome
task. This is the physician’s first opportunity to
cooperate fully with his attorney, and just as
much attention should be devoted in the prep-
aration of answers to interrogatories as would
be devoted to answering correctly the ques-
tions of the plaintiffs lawyers at trial.

Physicians as defendants are an unusually
intelligent and cognizant group of clients for
the attorney; in many respects they can be a
pleasure to work with. However, a physician
can make himself, to the attorney, what an
hysterical and distrustful patient is to the
physician. The attorney is definitely interested
in knowing whether or not you consider your-
self to have made an inexcusable error, a medi-
cally acceptable error, or no error at all. How-
ever, the attorney is totally willing to accept
your viewpoint, and no time need be devoted to
convincing your attorney that the patient is
crazy for bringing the lawsuit, or that the
patient’s lawyer is unscrupulous and worthy of
disbarment for filing the lawsuit. It is more
important to devote your attention to educat-
ing your attorney to the medical reasons why
you acted as you did.

Many physicians who are sued are so con-
cerned with the injustice of the claim that it is
difficult to communicate with them as to the
factual aspects of the case. We actually en-
countered recently a major case in which a
postoperative complication was reported by a
second physician. The defendant, our client,
did not believe the complication occurred. As a
practical matter, we could not call the second
doctor a liar, (the jury would have been of-
fended) so, it was necessary to answer the
question: "Assuming this complication did
occur, how can we explain it? How did it hap-
pen without negligence?” Our defendant doc-
tor, highly qualified in his field, never got past
the point of "assuming,” which he adamantly
refused to do. The answer was supplied by
another person in the field, with whom we con-
sulted, and the case was successfully defended.
However, its defense was truly jeopardized by
the defendant’s over-concern about the ob-
servations of his colleague, and the defendant’s
unwillingness to turn his attention from that
focal point to the real problems we outlined to
him.

Journal / March 1975 / Volume 68

A Defendant / SHORT, LAUGHLIN

A common question asked by the physician
who knows that he has been unjustly sued is,
"Can I bring countersuit for (slander) (malici-
ous prosecution)?” Such a countersuit is rarely
a feasible alternative, for the law will not
penalize the patient or his attorney for their
ignorance of the propriety of your diagnosis or
treatment. Most lawyers taking a malpractice
claim on behalf of a patient are totally ignor-
ant of whether the doctor has performed in a
medically acceptable fashion or not; they take
the case on a contingency fee, and by the time
they discover that the doctor, in all probability,
was not at fault, they have invested so much in
the case that they feel obliged to pursue it to
trial. Although this may seem unfair, it is a
relatively small price for the benefits of the
present system. At the least, don’t waste your
energy planning your countersuit; plenty of
time for that after you prevail as a defendant.

A common problem doctors encounter in
dealing with their lawyers is the inability of
any lawyer to "diagnose” a case, even after a
thorough examination of the client. Modern
pre-trial procedures do allow us to see most of
the whole of the other side’s evidence before
trial, and as this develops, the lawyer’s opinion
emerges. On the day of trial, however, even the
best lawyer cannot tell you "What’s going to
happen?” The twelve strangers picked that day
to sit in the jury box constitute an unknown,
comparable to having a patient with a com-
pletely unique juxtaposition of vital organs,
undetectable before the abdomen is opened.

PRACTICING DEFENSIVE MEDICINE

There has been much discussion in the liter-
ature concerning the practice of defensive
medicine. In talking with doctors, we often find
that they expect us to advocate the running of
many tests and the calling in of many consul-
tants in order to protect themselves from mal-
practice claims. This is not necessary.

From the standpoint of the lawyer who
would be defending you in the event of a mal-
practice claim, nothing is required of you as a
physician except to practice good medicine as
defined by the patient’s welfare. This is true
because there are no statutes or written direc-
tives of any sort stating that, for example, an
open reduction must be performed on a certain

type of fracture in order to avoid a charge of
negligence. Rather, the evidence is presented
to a jury, and they decide, in light of the
circumstances as explained by the physician
himself and other expert testimony, whether
an open reduction were a discretionary deci-
sion, in which case no negligence is involved,
or whether it were mandatory under the cir-
cumstances. The jury must consider all of the
circumstances, so that if the patient were a
poor surgical risk, for example, in light of our
experience with juries, we would not anticipate
that the jury would be critical of the physician
for adopting a course of conservative treatment
rather than one of anesthesia and surgery.
Thus, any time a physician’s actions, no matter
how poor the result, can be justified in light of
the doctor’s best medical judgment in the in-
terest of the patient, there is a strong defense.
This is not to say, however, that there are not
some defensive measures which a physician
can and should take in anticipation of a mal-
practice claim.

Such precautions do not deal with an al-
teration of diagnostic procedures or the se-
lection of treatment. Rather, they deal with
such things as keeping accurate records, in
order to document what was explained to the
patient, what the patient and the patient’s
family had to say in response, and what symp-
toms the physician relies upon in making his
diagnosis in selection of treatment. This is
vastly different from changing the number of
tests which are run or the extent of a physical
examination; rather, it is important to record
all those findings, both positive and negative,
on which the physician feels he can confidently
base such a diagnosis or selection of treatment.

It also becomes important in many lawsuits
to establish that the patient was instructed to
return and in fact did not do so; therefore, it is
desirable to keep records reflecting either that
a return appointment has been made, or, on
the patient’s chart, that the patient has been
instructed to return. These are clerical mat-
ters, not affecting the diagnostic or treatment
course of the patient, but nonetheless they are
often vitally important in the defense of the
malpractice claim.

LOOSE TALK SINKS SHIPS

Perhaps the highest duty of the physician in
avoiding malpractice claims, both against
himself and others, is the avoidance of rash

Oklahoma State Medical Association

statements. The general guideline is that a
physician, in talking with the patient or family
members, or indeed with anyone else, should
remain objective rather than subjective.

An untold number of lawsuits arise because
a physician, commendably disturbed by a poor
result, and seeking to console a distraught pa-
tient or family member with a concrete ex-
planation, makes some statement as to the
cause of the problem which is nothing more
than pure speculation on the part of the physi-
cian. This is of great legal significance which
need not be expanded upon here, but suffice to
say that a physician should never offer any ex-
planation with any more certainty than is an
actual medical probability. Too often, physi-
cians who are all too aware of the uncertainties
of the science of medicine, when confronted
with the lay patient or family member, seek to
give a "pat” answer which comes back to harm
them in court. Often this explanation indicates
the physician as being at fault.

Likewise, many physicians have found
themselves in a court of law because they an-
grily deplored a mistake by hospital personnel
to the family without knowing whether that
failure actually had any causal relationship to
the patient’s problem; as a result, the hospital
is sued, and the doctor joined as a defendant in
order that he be pressured into reiterating the
damaging statements he made in the past
against the hospital personnel. It is of utmost
importance that the uncertainties of medicine
be outlined to the patient and family from the
outset, particularly when a bad result has been
obtained.

An even more frequent cause of malpractice
suits is the "holier-than-thou” remark made by
the physician who sees the patient after the
bad result is obtained under the care of a prior
treating physician. It is totally amazing the
number of physicians who, upon examining a
patient who has had less than desirable results
from prior treatment, will exclaim, "What
butcher did this to you?” "Why in the devil
didn’t your doctor do such-and-such?” or
"Somebody really made a mess out of this!” In
almost every instance, the doctor making such
a statement has no knowledge of the prior
treatment, the problems which may have been
confronting the physician who treated the pa-
tient previously, or the patient’s own noncoop-
eration or failure to follow the prior physician’s
instructions. If you as a physician are guilty of
making such careless remarks without knowl-

Journal / March 1975 / Volume 68

edge of the facts, not only may you instigate a
lawsuit where none is justified, but you will
certainly be called as a witness against a
member of your own profession. This may
prove extremely embarrassing when you dis-
cover that there were extenuating circum-
stances which render your remark totally un-
justified.

This is not to say that one physician should
never criticize or testify against another physi-
cian; it is merely to urge all members of the
profession to restrain themselves from passing
judgment until all of the facts are in hand. We
have actually seen cases in which physicians
have made such statements to a patient when
in fact, had those physicians made the effort to
consult with the prior physician, they would
have learned facts which would have rendered
their own treatment more effective; some of
these subsequent treating physicians have
made gross errors because of their failure to
learn from a technically accurate medical
source the course of the patient’s prior disease
and treatment.

It is incumbent on any responsible physician
not to render any opinions as to cause or judg-
ment as to negligence, unless he feels confident
he (1) has all the facts and (2) is certain enough
of his opinion to be willing to so testify under
oath — because the greatest likelihood is that

eventually he will be asked to do just that.

Keep in mind that statements made by you
on a chart are just as much potential evidence
as oral remarks. Many entries on charts do not
rise above just that — mere remarks. This
should be avoided, as the fact that the remark
is in writing on a chart, that mysterious docu-
ment unread by lay persons — until trial! —
gives the comment added weight. "The doctor
would not have written it in the permanent
record unless it were so,” reasons the lay per-
son on the jury. Impressions, provisional diag-
nosis, and pure conjecture should be clearly
designated as such on the chart whenever un-
certainties need be recorded. Otherwise you
will find yourself explaining from the witness
stand that although you know what you said
(or wrote), that’s not what you meant . Often
true, but hard to explain!

Finally, as a general matter, try to be guided
by your lawyer. Don’t try to guide him in legal
matters. Do try to explain to him, in fullest
detail, all medically significant facts. And
satisfy yourself that he does understand those
facts and their interrelationship. Try to show

A Defendant / SHORT, LAUGHLIN

him the respect as a professional which you
demand for yourself. Human nature dictates
he will do a better job for you if you do. Above
all, remember he is already on your side; don’t
waste valuable time trying to win his approval,
but set about at once the tasks of defending as
he prescribes.

SETTLEMENT

There are many reasons your lawyer may
recommend settlement, most of them having
nothing whatsoever to do with any thought
that you were negligent. The trial lawyer must
weigh the probability of a judgment against
you, the range of the amount which would be
involved, the time consumed from the doctor’s
schedule by a trial, and an element unique to
malpractice, the doctor’s desire to defend on a
matter of principle rather than to pay even a
small sum.

Note, the lawyers decide the probable jury
reaction — not what he thinks it should be.
This is influenced by many factors. Horrible
injuries, for example, increase the likelihood
that the jury will disregard a plaintiff s weak
case on liability. Likewise, a single strong ex-
pert for plaintiff, lack of communication with
his own defendant, a very appealing plaintiff'
or a defendant with a negative personality,
bias of a judge or community — all may affect
the lawyer’s decision to recommend settlement
even though he believes strongly yours is a
case of no liability. Therefore, if he recom-
mends settlement, do not be offended, but
rather, ask him to explain (if he fails to volun-
teer) the factors he considers important in pre-
dicting what a jury will do. At this point, the
medical propriety of your conduct is not the
deciding factor. Once you understand his
reasons, you may accept or reject his advice,
but remember: advice to settle is not an ex-
pression by your lawyer that he feels you were
negligent and liable; it means nothing more
than that he thinks a jury might so find.

TRIAL

If you do go to trial, your lawyer will prepare
you to testify and will try to tell you what
cross-examination to expect. The "other side”
always puts their case on first, and may not
call every witness they have listed. Therefore,
it is impossible for your lawyer to tell you how

long the trial will last or when you’ll testify, as
you may even be called as part of the plaintiff s
case. Don’t take this as a lack of organization.
You can also help your lawyer by explaining
the problem to those doctors who may be tes-
tifying in your behalf. Many times we en-
counter belligerence when we cannot tell a
prospective witness a definite hour, or even a
certain day! This is impossible to avoid, as we
must wait until the plaintiff is through, and we
have no control over that.

Do not expect to communicate closely with
your lawyer during the actual trial. Events are
rapid in a trial; whole strategies may go "down
the tubes” with one question and answer, and
must be replaced in a matter of seconds. Your
lawyer must listen intently, even while feign-
ing inattention. Do not talk to him. Do not take
notes or write him notes. Your role is NOT that
of the advocate; it is as impassive as possible
except when on the stand. You should not ap-
pear to participate at all. There is one ex-
ception. Rarely, a new medical fact will arise
which you have not already explained to your
lawyer. You may need to write a note in this
instance, but this occasion is rare.

Look to your lawyer for protocol. One must
not look at or speak with jurors in a social fash-
ion, nor should one ever converse with anyone
within hearing of any juror. Do not try to make
friends with the jury; it insults their integrity
by suggesting they can be swayed from their
duty by bias. For the same reason, one never
thanks a juror for a favorable verdict, nor a
judge for a favorable ruling.

Your lawyer may leave you alone a good deal
of the time during trial, at recesses, or even at
lunch. He may need time to think or plan, or to
confer with co-counsel. He may be in chambers
arguing legal matters before the judge. He may
simply need to clear his head.

At all stages of preparation, settlement, and
trial, remember that, in a very real sense, you
are the "patient” and your lawyer has assumed
the role you usually play. Try to conduct your-
self as you would have any patient do — give
him your respect and trust, listen well, give
him all the information he needs, follow in-
structions, don’t try to do his job, or "treat”
yourself. Remember that a good patient is
easier to heal, and give your cooperation freely.
You will substantially enhance your own
chances for a "good result.” □

3200 Liberty Tower, Oklahoma City, Oklahoma

73102

Oklahoma State Medical Association

Malpractice: The National Situation

ED KELSAY

Oklahoma s malpractice situation has been
described as rran island of tranquility in a sea
of turmoil,” by an official of The Insurance
Company of North America. This comment
came during the research for this article on
the national malpractice situation.

The economical availability of professional
liability, or malpractice insurance is becoming
a daily concern for physicians throughout the
United States. According to an AMA report,
"premiums paid by physicians, surgeons, den-
tists and hospitals during 1974 probably
amount to $225,000,000 or more, based on pro-
jections from data in the report of the HEW
Commission on medical malpractice for the
year 1970 and earlier.”

For the past several years the major profes-
sional liability insurance problem, as seen by
most physicians, was the amount of the pre-
mium they would have to pay. However, now
the problem is becoming whether the coverage
will be available at any price.

Insurance magazines are replete with stories
about insurance companies abandoning the
malpractice market. Fewer and fewer com-
panies are showing interest in filling the void.

Journal / March 1975 / Volume 68

A notable example took place in the state of
New York. Employers Insurance of Wausau,
Wisconsin, announced in late 1973 that it
would terminate all of its malpractice coverage
in the state of New York as of May 1, 1975. The
company had had the New York State Medical
Society’s endorsement for 25 years.

Twenty thousand New York physicians
faced the possibility of being without profes-
sional liability coverage. Their total yearly
premiums to the company had amounted to
$40 million, but that amount was not enough.

It took NYSMS seven months to locate
another company that was willing to under-
write malpractice policies for its members. Ar-
gonaut Insurance Company agreed to enter the
market provided there was an across-the-board
93.5% hike in annual premiums. This increase
will mean that some high risk surgeons will be
paying as much as $14,329 for basic $1 million-
$3 million coverage.

(Most of the insurance companies writing
malpractice policies on the east and west coasts
insist on high limits basic coverage of $l-$3
million, as opposed to the more traditional cov-
erage of $100-$300 thousand.)

Even with the 93.5% premium increase, Ar-
gonaut was the low bidder. Some companies
had insisted on as much as a 200 - 300%
premium hike before they would consider writ-
ing in New York.

New York isn’t the only state with problems.
Several changes in companies writing mal-

Malpractice / KELSAY

practice in California prompted the state’s
Commissioner of Insurance, Gleeson L. Payne,
to say, "I believe we are on the threshold of
having no market for malpractice insurance.

About 30,000 doctors in that state pay up to
$25,000 a year in premiums for insurance,
premiums that are rapidly increasing because
of inflation and a growing number of mal-
practice claims.

Some doctors in California have suddenly
found themselves without insurance.
Approximately 2,300 California physicians not
only lost their professional liability coverage,
but are being assessed additional amounts, up
to 90% of their premiums, to insure future
claims are paid.

Casualty Indemnity Exchange, a Missouri-
based firm writing malpractice coverage in
California, found that its 1972 premiums were
actually inadequate to cover loss-
es and expenses.

Citing an almost $3 million deficit, the Cali-
fornia Department of Insurance cancelled all of
the malpractice policies and ordered the physi-
cian policyholders to pay an assessment rang-
ing from $300 to $9,000, depending on the
amount of coverage, into a special trust ac-
count to cover future losses.

Another group of doctors in southern Cali-
fornia found themselves changing insurance
coverage when their group professional liabil-
ity carrier, Hartford Insurance, announced it
planned to double its premiums. Although they
found a new carrier in Travelers, that company
insisted on a 30% premium increase plus an
increase in the minimum basic limits from
$100 thousand to $1 million.

Substantial premium increases are the rule
all across the country, not just on the east and
west coasts. The two companies writing cover-
age in North Carolina, St. Paul and Aetna, re-
quested an 82% and a 150% increase respect-
ively. New Jersey physicians were faced with
an increase from 5% to 200% depending on the
class they were in.

Other states showing increases were as fol-
lows: Wyoming, 56%; Maryland, 46%, Rhode
Island, 65%; Massachusetts, 65%; Wisconsin,
50%; and, Pennsylvania, 59% for Aetna and
44% for Medical Protective.

While Oklahoma physicians are faced with a
20% increase in premium from INA, physi-
cians in the state being underwritten by other

companies may see a 54.2% increase. This is
the amount requested by the national insur-
ance rating bureau, known as Insurance Ser-
vices Office.

According to the AMA report, "medical lia-
bility insurance programs sponsored by state
or local medical associations now exist in at
least 30 states. These programs provide some
measure of assurance for continued avail-
ability of coverage and realistic cost based on
loss experience. They cannot, however,
guarantee an end to increasing premiums or
complete freedom from problems.”

Some states that have not had preferred car-
riers in the past, now are looking for them. The
State Medical Society of Wisconsin undertook
such a search after the companies writing pro
fessional liability in that state took a get-tough
attitude.

St. Paul Fire and Marine Insurance Com-
pany in Wisconsin had stopped writing new
policies for anesthesiologists, emergency room
doctors, gynecologists, orthopedists, and plas-
tic surgeons. In addition, Medical Protective
and Aetna Insurance each said they would con-
tinue to write new policies only after close
scrutiny of each applicant. All of the companies
indicated they expected their premiums to in-
crease at least 50%.

The frequency of claims and their dollar
value has increased dramatically. According to
New York statistics, ten years ago claims av-
eraged four per every 100 physicians insured;
but when 1972 litigation is completed, the
state estimates there will be 8.3 claims per 100
insured physicians.

St. Paul Fire and Marine published a
nationwide summary of pending medical mal-
practice cases as of March 31, 1974. That

Ed Kelsay was graduated from the Oklahoma
City University School of Law in 1967. He is
presently Associate Executive Director of the
Oklahoma State Medical Association; Adjunct
Professor of Medical Law and Ethics, Okla-
homa University School of Allied Health Man-
power, Oklahoma City; and Visiting Lecturer
on Medical Law, Oklahoma University School
of Medicine. Professional organizations of
which he is a member include the American
Bar Association, Oklahoma State Bar Associa-
tion, Oklahoma County Bar Association, the
American Association of Medical Society Ex-
ecutives and Associate-in-law member of the
American College of Legal Medicine.

Oklahoma State Medical Association

summary showed that 15.4% of its Class 5
physicians were facing outstanding claims.
Each of those claims averaged $14,623.

As could be expected Class 1 physicians had
the least percent of frequency of outstanding
claims, 3.7%, but ranked second in severity
with an average claim of $10,705. Frequency
for Class 2 physicians was 6.2% with an aver-
age of $9,497 per claim. Class 3 physicians had
an average claim of $11,554, with a frequency
of 7.1%. Thirteen and eight-tenths percent of
the Class 4 physicians had outstanding claims
with an average of $13,000 each.

According to the AMA report, the situation
regarding number of claims may get even
worse. The report states, ''although the degree
of injury varies greatly, it is generally agreed
that there are a substantial number of serious
injuries which occur at present, but do not de-
velop into claims. Each year, more of these
serious injuries do become claims. This results
in an increased loss experience and conse-
quential increases in the cost of insurance.”

The report points out that it is reasonable to
estimate that the annual number of patient
visits to physicians and dentists amount to ap-
proximately 3.25 billion. Each such patient
visit is an exposure to some risk of a medical
injury. The report says, "if the average prob-
ability of injury were no more than one in ten
thousand visits, that would be a lower rate of
risk than that found in most human activities,
but it would indicate a total annual number of
injuries amounting to 322,600.” If the rate
were one in 1,000 visits, the total number of
injuries would be 3.25 million. Either of these
figures is much higher than the total number
of medical liability claims being made annu-
ally at the present time.

The AMA report goes on to note, . .the
trend in the courts is in the direction of impos-
ing liability on someone for every injury that
occurs. This is true in all kinds of litigation,
not only malpractice litigation. It is also only a
trend, which has a long way to go before it
reaches the point at which every injury is com-
pensated. That is why it is unlikely that the
cost of malpractice insurance will level off for
some years to come.”

Robert J. Miller, a vice-president for Medical
Protective Company of Ft. Wayne, Indiana,
said, . .the most distressing aspect of
today’s malpractice situation is a willingness
of juries to award large sums of money to a
plaintiff and the willingness of the courts to

uphold these verdicts even in the absence of
proof the doctor did anything wrong.

"Our society has developed an acute aware-
ness of injured individuals and, it would seem,
desires that injuries be compensated irrespec-
tive of responsibility.”

A report compiled by the St. Paul Fire and
Marine Companies across the nation may help
explain why juries tend to make large awards
in malpractice cases. The report notes that 18%
of all medical malpractice injuries result in
death, 19% leave permanent effects, and the
rest are temporary. In this latter group, 12%
cause psychological scars regardless of the
physical damage extent.

Lawyers agree that injuries and disfigura-
tions that are obvious to a jury weigh heavily
in favor of the plaintiff. Top trial lawyers teach
their clients how to "display” their injuries to
the best advantage in order to gain sympathy
from the jury.

The AMA report ended on a disheartening
note by stating, ". . .until a point is reached at
which substantially all potential claims have
become actual claims, insurance loss exper-
ience is apt to continue to rise every year. Un-
less appropriate remedial legislation can be
enacted in the several states, there does not
seem to be any end in sight for the continually
increasing cost of medical liability insurance.
Under present conditions, however, the best
assurance physicians can have for continuing
insurance coverage is through a program spon-
sored by their medical association.”

The professional liability situation prompted
a memorandum by a company that specializes
in reinsurance. Bowes and Company, Inc, of
Missouri notified all its clients that they
should keep Lloyd’s, the large underwriting
organization in London, England, in mind for
malpractice liability insurance coverage.

The memorandum pointed out, however,
that Lloyd’s underwriters are looking at each
malpractice risk individually and that they
will not write hospitals, doctors who are em-
ployed by hospitals, anesthesiologists, "and a
few other classifications according to special-
ties and claims experience.”

The professional liability situation is best
summed up by one sentence in the company’s
memorandum: "The Lloyd’s market is expen-
sive, but in this day and age any market is
better than none.” □

601 N.W. Expressway, Oklahoma City, Oklahoma
73118

Journal / March 1975 / Volume 68

GENERAL

FAMILY

PHYSICIAN

Ambulatory Health Center in Oklahoma City
serving a population mixed socially, economi-
cally and racially needs a General/Family
Physician. Will be free of non-medical admin-
istrative responsibilities — can devote major
efforts to patient care. Will be a non-salaried
faculty member of the Department of Family
Practice, Community Medicine and Dentistry of
the University of Oklahoma Health Sciences
Center. Salary $25,000.00 — $30,000.00 with
excellent fringe package.

SEND RESUME
Perry A. Klaassen, MD
Medical Director

Mary Mahoney Memorial Health Center
P.O. Box 307

Spencer, Oklahoma 73084
405 769-3301

EQUAL OPPORTUNITY EMPLOYER

MARK YOUR

CALENDAR

NOW!

OKLAHOMA MEDICAL

SUMMIT 75

ril 23rd-26th, 1975

Lincoln Plaza Forum

Oklahoma City

IMPORTANT INFORMATION: This is a Sc
ule V substance by Federal law; diphenox
HCI is chemically related to meperidine
case of overdosage or individual hypersen
ity, reactions similar to those after meper
or morphine overdosage may occur; treat
is similar to that for meperidine or morf.
intoxication (prolonged and careful mot
ing). Respiratory depression may recur in
of an initial response to Nalline® (nalorp.
HCI) or may be evidenced as late as 30 h
after ingestion. LOMOTIL IS NOT AN INI
UOUS DRUG AND DOSAGE RECOMMEI
TIONS SHOULD BE STRICTLY ADHERED
ESPECIALLY IN CHILDREN. THIS MED
TION SHOULD BE KEPT OUT OF REACh
CHILDREN.

Indications: Lomotil is effective as adjuncts j
apy in the management of diarrhea.

Contraindications: In children less than 2 ye£
to the decreased safety margin in young
groups, and in patients who are jaundiced or
sensitive to diphenoxylate HCI or atropine.

Warnings: Use with caution in young childr
cause of variable response, and with extrerr
tion in patients with cirrhosis and other ad
hepatic disease or abnormal liver functior
because of possible hepatic coma. Diphen
HCI may potentiate the action of barbiturate:
quilizers and alcohol. In theory, the concurrt
with monoamine oxidase inhibitors could prec
hypertensive crisis.

Usage in pregnancy: Weigh the potential b
against possible risks before using during
nancy, lactation or in women of childbearin
Diphenoxylate HCI and atropine are secreted
breast milk of nursing mothers.

Precautions: Addiction (dependency) to diph
late HCI is theoretically possible at high dosa
not exceed recommended dosages. Administ
caution to patients receiving addicting drt
known to be addiction prone or having a his
drug abuse The subtherapeutic amount of atrc
added to discourage deliberate overdosage;
observe contraindications, warnings and prec<!
for atropine; use with caution in children sino
of atropinism may occur even with the recomn
dosage.

Adverse reactions: Atropine effects include
of skin and mucous membranes, flushing and
retention. Other side effects with Lomotil i
nausea, sedation, vomiting, swelling of the
abdominal discomfort, respiratory depression,
ness of the extremities, headache, dizziness, cj
sion, malaise, drowsiness, coma, lethargy, an ;
restlessness, euphoria, pruritus, angione'
edema, giant urticaria and paralytic ileus.

Dosage and administration: Lomotil is cont
cated in children less than 2 years old. Us
Lomotil liquid for children 2 to 12 years of;
ages 2 to 5 years, 4 ml. (2 mg.) t.i.d.; 5 to 8 yt
ml. (2 mg.) q.i.d.; 8 to 12 years, 4 ml. (2 i!
times daily; adults, two tablets (5 mg.) t.i.d.
tablets (5 mg.) q.i.d. or two regular teaspo
(10 ml., 5 mg.) q.i.d. Maintenance dosage may
low as one fourth of the initial dosage. Make
ward dosage adjustment as soon as initial syrr
are controlled.

Overdosage: Keep the medication out of the
of children since accidental overdosage may
severe, even fatal, respiratory depression. Si |j
overdosage include flushing, lethargy or corr
potonic reflexes, nystagmus, pinpoint pupils,
cardia and respiratory depression which may
12 to 30 hours after overdose. Evacuate storm!
lavage, establish a patent airway and, when i
sary, assist respiration mechanically. Use a n£
antagonist in severe respiratory depression, i |
vatlon should extend over at least 48 hours.

Dosage forms: Tablets, 2.5 mg. of diphenci
HCI with 0.025 mg. of atropine sulfate. Liqu,'
mg of diphenoxylate HCI and 0.025 mg. of at
sulfate per 5 ml. A plastic dropper calibrated
crements of Vi ml. (total capacity, 2 ml.) a
panies each 2-oz. bottle of Lomotil liquid.

Searle & Co.

San Juan, Puerto Rico 00936

Address medical inquiries to:

G. D. Searle & Co.

Medical Department, Box 5110,

Chicago, Illinois 60680

SEARLE

Oklahoma State Medical Association

Physician Involvement in
Workmen’s Compensation Cases

DICK LYNN

Legal requirements connected with treatment
of industrial injuries, with reporting pro-
cedures, are outlined. Cooperation between
treating physicians and claims people

is recommended.

In order to understand the legal require-
ments imposed on the physician once he ac-
cepts a Workmen’s Compensation case, it is
helpful to have some background concerning
the evolution of Workmen’s Compensation
Laws.

Workmen’s Compensation is an outgrowth of
the industrial revolution. It is social legislation
intended to provide certain benefits to the in-
jured worker once he has met basic require-
ments. These are: (1) He must have sustained
an accidental injury. (2) It must arise out of his
employment. (3) It must be during the course of
his employment.

Once these basic requirements have been
met the employer and its insurance carrier are
legally required to provide: (1) medical treat-
ment as defined by statutes; (2) payment of
temporary total compensation benefits as a
percentage of the average earnings with a
maximum limitation, usually by the week; (3)
payment for partial or total permanent disabil-
ity as set out in the schedule of compensation,
also with a maximum limitation based on a
percentage of average earnings.

Physician involvement in Workmen’s Com-
pensation cases obviously is in the area of med-
ical treatment. Each physician should have

available that section of the Workmen’s Com-
pensation Act pertaining to medical treatment.
Copies of the entire law are available, at a
cost of $2.00 per copy from the State Industrial
Court, P.O. Box 53038, State Capitol Station,
Oklahoma City, Oklahoma 73105.

In 1973 the Oklahoma Legislature made ex-
tensive amendments to the "medical attention”
portion of the Workmen’s Compensation stat-
utes. That portion of the law, with points of
particular interest in italics, now reads as fol-
lows:

The employer shall promptly provide for
any injured employee such medical, surgi-
cal, or other attendance or treatment, nurse
and hospital service, medicine, crutches, and
apparatus as may be necessary after the in-
jury. The attending physician shall supply
the injured employee and the employer with a
full examining report of injuries found at the
time of examination and proposed treatment,
this report to be supplied within seven days
after the examination; also, at the conclusion
of the treatment the attending physician
shall supply a full report of his treatment to
the employer of the injured employee.

The employer’s selected physician shall
have the right to examine the injured em-
ployee. A report of such examination shall be
furnished the injured employee within seven
days after such examination.

If the employer fails or neglects to provide
the same within a reasonable time after
knowledge of the injury, the injured em-
ployee, during the period of such neglect or
failure, may do so at the expense of the em-
ployer; provided, however, that the injured
employee, or another in his behalf, may ob-
tain emergency treatment at the expense of
the employer where such emergency treat-

Journal / March 1975 / Volume 68

Compensation / LYNN

ment is not provided by the employer. Not-
withstanding any other provision of this sec-
tion, the employee may select a physician of
his choice to render the necessary medical
treatment, at the expense of the employer;
provided, however, that the attending
physician so selected by the employee shall
notify the employer and/or the insurance
carrier within a reasonable time not to ex-
ceed seven days after examination or treat-
ment was first rendered. The term physician
as used in this section shall mean any per-
son licensed in Oklahoma as a medical doc-
tor, chiropractor, chiropodist, dentist, os-
teopathic physician or optometrist. If such
injured employee should become deceased,
whether or not he has filed a claim, such fact
shall not affect liability for medical atten-
tion previously rendered, and any person or
persons entitled to such benefits may en-
force charges therefore as though such em-
ployee had survived. . . .

The remainder of that section deals with
payment mechanisms, reasonableness of
charges, and enforceability of payments to
physicians.

It will be noted that the very first of this
quoted section requires that the employer
promptly provide such medical, surgical or
other attendance or treatment as may be
necessary after the injury. Special attention is
called to the requirement that "the attending
physician shall supply the injured employee
and the employer with a full examining report
of injuries found at the time of examination
and proposed treatment, this report to be sup-
plied within seven days after the examination
. . .” The statute then goes on to require that
at the conclusion of treatment the attending
physician shall supply full report of his treat-
ment to the employer of the injured employee.

The State Industrial Court of Oklahoma has
jurisdiction in Workmen’s Compensation
cases. Certain forms have been designed to be
used in the processing of Workmen’s Compen-
sation claims. Those with which physicians
will have contact are: Form 4, Attending
Physician’s Report; Form 19, to be used by the
physician in case of dispute as to the reason-
ableness or compensability of his charges; and
Order For Medical Examination. The last of
these may never be seen, although State In-
dustrial Court occasionally does exercise its

right to direct a claimant to a physician for
examination. Other forms, not statutory,
which physicians may see are "Surgeon’s Re-
port,” "Final Report and Bill.”

In routine cases physicians will be expected
to complete either Form 4 or the Surgeon’s Re-
port. Generally these forms are furnished by
the insurance carrier and should be returned
promptly to the carrier. Since it is the statu-
tory obligation of the employer and insurance
carrier to provide medical care, the privileged
communication between physician and patient
does not exist. However, if an insurance carrier
requests any medical information other than
that relating to the injury which is being
treated as a compensation case, the physician
should require a medical information authori-
zation from the patient.

At the conclusion of treatment in a routine
case the physician should furnish the "Final Re-
port and Bill” on forms furnished by the in-
surance carrier. On both forms particular em-
phasis should be placed on the questions of
permanent disability and the date of release to
return to work.

In those cases involving obvious permanent
disability, the insurance carrier will ap-
preciate immediate notice by telephone, where
it is possible, or notice to the employer, so con-
sultation by a specialist may be arranged
where indicated.

In cases involving permanent disability,
narrative reports are indicated at regular in-
tervals. The question of an additional charge
for such reports should be resolved with the
insurance company involved. In general, un-
less the demand of the insurance company for
interim reports is excessive, the cost of such
reports should be included in the cost of treat-
ment.

At the conclusion of treatment in cases in-
volving partial permanent disability, a narra-
tive report always should be furnished and it j

Dick Lynn received his law degree from
the Oklahoma City University in 1951. He is
currently Staff Attorney for The Hartford Insur-
ance Group. Mr. Lynn is a member of the Okla-
homa Bar Association; a Past-President of the
Oklahoma City Claim Men Association; a char-
ter member, Past-President, member of the
Executive Committee, and currently chairman of
the Medical Claims Liaison Committee of Okla-
homa Claim Men Association, Inc.

Oklahoma State Medical Association

should meet the requirements of Rule 12 of the
State Industrial Court. The rule is quoted
below:

RULE 12. MEDICAL EVIDENCE BY
WRITTEN REPORT

The court favors and encourages the pro-
ducing of medical evidence by written reports
which shall include:

(a) history

(b) complaints

(d) extent of disability whether temporary
or permanent

(e) cause of disability found

(f) medical treatment, if any, that may be
necessary or recommended

(g) whether temporary total disability has
terminated and date of termination and
whether permanent partial disability ex-
ists and is ready for evaluation.

(h) detailed factors and reasons upon which
rating of permanent disability is based.

It is a general observation that most prob-
lems in human relations result from the lack
of, or poor communications. This is equally
true in the relationship between the physician

and claim representative of the insurance car-
rier in a Workmen’s Compensation case. Ex-
perience indicates that most misunder-
standings can be avoided if on the first case of
any consequence the physician can make him-
self available for a short conference with the
claim representative. Five minutes or less
should suffice in all except cases of extreme
severity.

The claim representative is admonished
never to appear at the physician’s office unan-
nounced. He should make arrangements
through the physician’s appointment desk and
the physician should make an effort to see
him promptly at the appointed time. Like the
physician, the claim representative has a busy
schedule and has many contacts which he must
make during the course of any working day.

The Workmen’s Compensation Laws are ex-
tremely complicated. Claim representatives
must be intimately familiar with the ins and
outs and quirks of that law. They can be a val-
uable source of information to physicians and
stand ready to answer or find the answer for
any question that a physician might have. □

P.O. Box 26503, Oklahoma City, Oklahoma 73126

Announcing

ANNUAL SPRING SYMPOSIA

GYNECOLOGY AND OBSTETRICS
THE OVARY

MAY 29TH AND 30TH, 1975
THE UNIVERSITY OF OKLAHOMA HEALTH SCIENCES CENTER
OKLAHOMA CITY, OKLAHOMA

The Annual Spring Symposia this year features an outstanding guest faculty for a two-day meeting
devoted to a comprehensive discussion of the Ovary. Discussions will be concerned with the physiol-
ogy, pathology and therapy of the ovary and ovarian disorders. As in previous symposia, there will be
ample opportunity for interaction between the registrant and the faculty.

GUEST FACULTY

RICHARD C. BORONOW, Professor of Obstetrics & Gynecology, University of Mississippi School of
Medicine, Jackson, Mississippi

RICHARD J. BLANDAU, Professor of Biological Structure, University of Washington School of
Medicine, Seattle, Washington.

A. BRIAN LITTLE, Professor of Obstetrics & Gynecology, Department of Reproductive Biology,
Case-Western Reserve University School of Medicine, Cleveland, Ohio

L. RUSSELL MALINAK, Associate Professor of Obstetrics & Gynecology, Baylor College of Medicine,
Houston, Texas

Journal / March 1975 / Volume 68

Professional Liability: The
Oklahoma Situation

ED KELSAY

Even with a 20% premium increase,
Oklahoma physicians have one of the best
professional liability insurance situations in
the nation today. The nearly 2,000
OSMA members insured by IN A pay
a lower premium than some of their colleagues

right here in the state.

Oklahoma physicians saw a 20% increase in
their professional liability premiums effective
January 1 of this year. The increase affected
nearly 2,000 Oklahoma physicians who carry
their professional liability insurance through
the Insurance Company of North America’s
wholly owned subsidiary, Pacific Employers
Indemnity Company.

The rate increase, which was approved by
the OSMA’s Council on Insurance, is only the
third in the association’s eight-year relation-
ship with INA. While the rule nationwide
seems to be yearly increases, Oklahoma physi-
cians have seen only three since 1967, offset by
a 10% dividend that was paid during 1968.

The OSMA’s relationship with INA began on
December 10, 1966, when the association’s
House of Delegates authorized the Council on
Insurance to enter into a contract with INA as ,
the association’s preferred professional liabil-
ity insurance carrier.

That contract has proved to be unique among
the nation’s many medical societies. It is bene-

ficial to both the insurance carrier and the as-
sociation.

In return for the OSMA’s endorsement of
INA as the preferred carrier, the company
promises to do several things:

First, the company agrees to furnish
promptly the OSMA with a copy of any report
or claim or incident reported to it by a physi-
cian or surgeon insured under the program.
This prompt reporting will allow the associa-
tion to spot malpractice trends before they be-
come well developed.

The company also agrees to keep the associa-
tion fully informed on losses, reserves, and the
final disposition and payment on any claim.

Another protection included in the contract
is an agreement that INA will provide the
OSMA with a list of all insured physicians and
surgeons at least twice each year. This list will
include the physician’s name, policy number,
policy anniversary date, and limits of profes-
sional liability. This certified list is retained at
the OSMA office to be used, if necessary, years
from now to prove that a physician did, in fact,
have professional liability coverage on a cer-
tain date.

The company also agrees to notify the OSMA
at least ten days before it initiates any action
to cancel, reduce limits, or refuse to renew the
malpractice insurance of any association
member. During that time, the association
may object to the action proposed and enter
into direct negotiations with the company in
order to protect its member.

Other sections of the contract call for the
INA to consult with the association before it
makes any change in rates, to establish a rate

Oklahoma State Medical Association

structure that would be on a statewide basis
with no surcharges to be added because of
geographical location, legal counsel for the de-
fense of professional liability claims may be
recommended by the association, and both par-
ties agree to give at least six months notice
prior to the proposed cancellation of the rela-
tionship.

In return for all of these guarantees by the
company, the OSMA agrees to cooperate fully
in the processing of professional liability
claims and to supply, if needed, expert guid-
ance to INA regarding the medical merit of a
claim.

In addition to endorsing INA as the profes-
sional liability carrier of choice, the association
also agreed to provide all reasonable assistance
in promoting physician-enrollment in the pro-
gram.

One of the last provisions in the contract is
that the OSMA agrees, "when requested by
INA, to support INA in filing for appropriate
rate changes after consultation between the
parties has been had and both parties agree
that a change in the rates (either up or down) is
warranted under the circumstances.” This is
exactly what happened last summer when the
OSMA Council on Insurance met with INA
representatives to work out the 20% premium
increase for 1975.

Based on the general economic situation in
the country and the Oklahoma loss experience,
the Council notified the Oklahoma Commis-
sioner of Insurance that they concurred in the
premium increase being sought by INA’s
Pacific Employers Indemnity Company.

If that rate increase had stood alone, without
any increase by other companies selling the
same type of insurance in Oklahoma, the INA
rate would still have been well below the so-
called bureau rate for all physician classes in
the state. As an example, the INA rate plus the
20% premium increase would be $203 for a
Class 1 physician. That same physician, pur-
chasing identical coverage from a bureau com-
pany, would pay $297.

Within 15 days after the date the INA pro-
posed its 20% premium increase to the State
Board of Property and Casualty Rates, the In-
surance Services Office (ISO), the new name
for the old Insurance Rating Bureau, applied
for a 60% premium increase for its member
companies. This means that the Class 1 physi-
cian purchasing his coverage from a company
other than INA could pay as much as $475 for

coverage that could be purchased for $203
under INA’s new rate.

If the Insurance Services Office premium
rates are accepted by the Insurance Commis-
sion, Oklahoma physicians insured through
those companies may be paying as much as
150% more than their colleagues insured
through INA.

Another change that is being made across
the nation is in the classification of physicians.
INA is currently using five classes of risk.
Some companies are now proposing twelve
classifications, and there are indications that
ISO may seek such a change for its companies
doing business in Oklahoma.

The five classifications currently being used
by INA are as follows:

Class 1 physicians are general practitioners
and specialists who do not perform obstetrical
procedures or surgery, other than incision of
boils and superficial abscesses or suturing of
skin and superficial fascia, and who do not or-
dinarily assist in surgical procedures.

Class 2 applies to general practitioners and
specialists who perform minor surgery, includ-
ing obstetrical procedures not constituting
major surgery, or who assist in major surgery
on their own patients. For purposes of this
classification, tonsillectomies, adenoid-
ectomies, and Caesarean sections shall be con-
sidered major surgery.

Class 3 includes specialists and general
practitioners who perform surgery or assist in
major surgery on other than their own pa-
tients.

Class 4 includes cardiac surgeons, otolaryn-
gologists not doing plastic surgery, general
surgeons, thoracic surgeons, urologists and
vascular surgeons.

Journal / March 1975 / Volume 68

Liability / KELSAY

Class 5 physicians are those practicing in the
specialties with the highest medical-legal
risk. These include anesthesiologists, neuro-
surgeons, obstetricians, gynecologists, ortho-
pedists, otolaryngologists doing plastic
surgery, and plastic surgeons.

As of December 31, 1973, Oklahoma physi-
cians had paid $4,226,746 in premiums since
the program began in 1967. Actuaries working
for the insurance company estimate that ulti-
mate losses will reach $3,625,277 at some point
in the future. However, the total loss grows
worse with each additional year of experience.

The major problem insurance companies
have in figuring professional liability pre-
miums is what is known as "lag time.” This is
the period between the time an injury occurs
and the time the claim is finally settled.

This "lag time” problem has been increasing
in the past few years. While Oklahoma physi-
cians paid $1,152,319 in premiums during
1973, INA estimates that its ultimate loss on
that year will be $1,520,988. Slowly but surely
over the past eight years the amount of ulti-
mate loss to be insured has been creeping up on
the amount of earned premium. It was only in
1973 that the projected loss exceeded the
earned premium amount.

Although there is a statute of limitations in
Oklahoma law, it does not begin to run until
the patient knows, or should know, that he was
injured. In situations where pieces of surgical
apparatus are left inside the body, the patient
may not discover their presence for many
years. While an injury may occur today, it may
not become an active claim for 10 to 20 years.
There is one case in Oklahoma in which the lag
time was 21 years between the date of injury
and the final settlement of the claim.

In its report to the 1974 OSMA House of
Delegates the Council on Insurance stated,

It is hoped that the premium cost can be
held relatively stable in the coming years,
but we must all recognize that malpractice
claims and awards are on an upswing across
the nation. While we have been favored by
a better malpractice climate than other
states, the number of claims and the amount
of the dollar demands are continuing to
rise in Oklahoma.

The Council on Insurance will under-
take various claims prevention programs
during the coming year in order to help
stabilize our position as much as possible.
We have an excellent working relationship
with the Insurance Company of North
America, and while it is entirely possible
that we cannot continue to hold a stable
premium in the face of increasing threats,
we are satisfied that INA will continue to
provide a market for us at the best possible
rates dictated by the circumstances.

This article and other articles in this issue of
the OSMA Journal are a part of the Council’s
Claims Prevention Program. One of its long
term projects is the continuing availability of
the OSMA Professional Liability Manual for
physicians. This was originally published in
1968 and copies are still available from the
OSMA office. The manual contains informa-
tion on doctrines of law that are of importance
to physicians, pointers on how to avoid mal-
practice situations, and a series of forms and
suggested letters to be used in medical prac-
tice.

One or more copies of the manual are avail-
able upon request to the OSMA office in
Oklahoma City. □

601 N.W. Expressway, Oklahoma City, Oklahoma
73118

MARK YOUR CALENDAR NOW!

OKLAHOMA MEDICAL SUMMIT 75

April 23rd-26th, 1975—LIncoln Plaza F o r u m — Oklahoma City

A combined meeting of the Oklahoma State Medical Association, the Oklahoma City Clinical Society and the
Oklahoma Academy of Family Physicians.

Oklahoma State Medical Association

News From
The Oklahoma State
Department of
Health

ANTIRABIES TREATMENT

As spring approaches animal rabies is on the
increase again in Oklahoma. A review of
human antirabies prophylaxis is in order. The
following recommendations can be modified
according to knowledge of the species of the
biting animal, circumstances surrounding the
bite incident, and vaccination status of the
animal.

Ideally, post exposure rabies prophylaxis
should include:

1. Thorough flushing and cleansing into the
wound with soap solution. Quaternary am-
monium compounds may also be used (remove
all soap since soap neutralizes activity of
quaternary ammonium compounds);

2. If the biting animal is rabid, has disap-
peared or is a wild carnivore, antirabies serum

is indicated. The recommended dose of an-
tirabies serum is 40 I U/kg (1 vial / 55 pounds).
Up to 50% of the antiserum should be used to
thoroughly infiltrate the wound and the rest
administered intramuscularly. Tests for
hypersensitivity must be performed unless
human origin rabies immune globulin (HRIG)
is used. HRIG is in very short supply and
should be used only in persons hypersensitive
to equine serum;

3. Duck Embryo Rabies Vaccine should then
be administered. Twenty-one doses (two per day
for seven days and one per day for an additional
seven days) are the recommended primary
series when antiserum or HRIG are used.
Three booster doses of vaccine are also recom-
mended at 10, 20 and 90 days after the comple-
tion of the primary series;

4. All patients should have serum tested for
neutralizing antibody three-four weeks after
the last booster;

5. Tetanus prophylaxis and bacterial in-
fection control as indicated. ^

REFERENCES:

1. PHS Advisory Committee on Immunization Practices

2. WHO Expert Committee on Rabies, Sixth Report

COMMUNICABLE DISEASES IN OKLAHOMA FOR JANUARY, 1975

DISEASE

January

1975

January

1974

Decembff

1974

Total To Date
1975 1974

Amebiasis

Brucellosis

Chickenpox

125

161

187

Encephalitis, Infectious

Gonorrhea (Use Form ODH-228)

998

878

1113

998

878

Hepatitis, A, B, Unspecified

100

119

Leptospirosis

—

Malaria

—

Meningococcal Infections

Meningitis, Aseptic

Mumps

Rabies in Animals

Rheumatic Fever

Rocky Mountain Spotted Fever

Rubella

Rubella, Congenital Syndrome

Rubeola

Salmonellosis

Shigellosis

103

106

Syphilis, Infectious

(Use Form ODH-228)

Tetanus

—

Tuberculosis, New Active

Tularemia

—

Typhoid Fever

Whooping Cough

—

Journal / March 1975 / Volume 68

nenjos

Oklahoma Medical Summit To Be “Biggest and Best”

Members of the committee planning Ok-
lahoma Medical Summit ’75 have declared that
it should be the "biggest and best” medical
meeting ever held in Oklahoma. Summit, the
combined annual meeting of The Oklahoma
State Medical Association, Oklahoma
Academy of Family Physicians, and the Ok-
lahoma City Clinical Society, is expected to
draw over 3,000 persons.

Scheduled for April 23rd-26th in Oklahoma
City’s beautiful Lincoln Plaza Hotel, Summit
will feature over 50 hours of continuing medi-
cal education for physicians and allied health
care personnel. Nearly 100 scientific, medical
and pharmaceutical exhibits will be available
for viewing. Wet clinics will be offered each
day featuring actual "how to” demonstrations.

In addition to the three sponsoring organiza-
tions, many medical specialty and allied medi-
cal organizations are participating in the
program.

Three "superstar” luncheons are planned.
The first will be held Thursday noon, April
24th, and will feature a presentation by Herb
Holden, MD, President of the American
Academy of Family Physicians. Friday’s
speaker will be Phil Thorek, MD, one of the
nation’s most sought after physician-speakers.
Malcolm Todd, MD, President of the American
Medical Association will be Saturday’s
speaker.

Two other programs featuring "superstars”
will be held during Summit. On Friday morn-
ing Doctor Phil Thorek and William Thurman,
MD, new provost for the Oklahoma University
Health Sciences Center will speak. A Saturday
afternoon program tentatively features Gover-
nor David Boren and Henry Simmons, the Di-
rector of the Professional Standards Review
Office in Washington, DC.

Scientific programs of interest to all physi-
cians will be offered each day during Summit.
At the same time, programs of specific interest
to medical specialties will be offered.

Programs on Thursday include a special sec-
tion on Immunology, Allergy, Obstetrics and

Gynecology, Pediatrics, and Surgery. Pro-
grams for allied health care personnel will in-
clude those presented by the Nurses Associa-
tion of the American College of Obstetricians
and Gynecologists, the Oklahoma State Nurses
Association, the Medical Records Association
and the Occupational Therapists.

Friday’s Scientific Program for physicians
will include a full-day session on Cancer spon-
sored by the Oklahoma Cancer Society. The
Heart Association will sponsor a half-day ses-
sion, as will the Psychiatrists, Ophthal-
mologists, Otolaryngologists, and Pathologists.
Allied health programs will be offered by the
Nurses Association, Dietitians Association,
Cytopathologists, Physicians Assistants and
the Medical Records Association.

On Saturday the emphasis will be on
socioeconomics for physicians. However, scien-
tific programs will be offered on Arthritis, Or-
thopedics, Urology, and Anesthesiology. A spe-
cial half-day seminar on Hyperlipidemia will
be sponsored by the Oklahoma Medical Re-
search Foundation. In addition, there will be a
special half-day program planned by the medi-
cal students.

Saturday’s program for allied health care
personnel will include sections on Cytopathol-
ogy, Operating Room Nurses, and Physicians
Assistants.

Three continuing programs will be offered
throughout Summit ’75. The Tulsa Cancer Soc-
iety will sponsor an exhibit and a proctoscopic
clinic for three days. In addition, the Part B
Medicare Carrier for Oklahoma, Aetna, will
sponsor a three-day workshop for physicians
and their employees on the processing and
handling of Medicare claims. A special two-day
seminar, with a limited enrollment of 40
physicians, is being offered by the Smith, Kline
and French Public Speaking Team. In two
full-days the 40 enrollees will receive the equi-
valent of a full semester’s course in Public
Speaking.

The social side has not been forgotten. The
Oklahoma State Medical Association

first social function during Summit ’75 will be
the Early Bird Party, Wednesday evening,
April 23rd. The party will start with a cocktail
reception in the Lincoln Plaza Congress Room
and will then adjourn to the Plaza Playhouse
for dinner and a play. The evening will be
casual and dinner will be barbeque.

Although Thursday evening is open, there
will be an early Keg and Oyster and Wine and
Cheese Tasting Party starting about 5:00 pm
The Keg and Oyster Party is being sponsored
by Marion Laboratories. The Wine and Cheese
Tasting is designed to accommodate those with
a refined pallet.

Thursday evening will then be open for spe-
cialty societies or alumni association dinners.
Such a dinner is already being planned by the
alumni of the Oklahoma University Medical
School.

Friday evening will feature the Presidents’
Inaugural Dinner-Dance, honoring the three
incoming and outgoing presidents of the spon-
soring organizations. It will start at 6:30 pm
with a cocktail reception in the Congress Room
and will then adjourn to the Plaza Playhouse
for a gourmet dinner. (The play will not be of-
fered). A dance will start at 8:30 promptly.

Tickets for the Early Bird Party must be or-
dered in advance. They are $25 per couple,
$12.50 per person, and include the social hour,
dinner and the theater. Tickets for the Presi-
dents’ Dinner will be $30 per couple, all inclu-
sive, with exception of after dinner drinks, dur-
ing the dance. Tickets for the luncheons each
day will be $5.00 each. □

New Address For Oklahoma
Narcotics and Drugs Commission

Oklahoma’s Office of Narcotics and Danger-
ous Drugs Control has been moved to Room
680 in the Jim Thorpe Office Building in the
State Capitol complex in Oklahoma City.

The new mailing address for the commis-
sioner is P.O. Box 53344, State Capitol Station,
Oklahoma City, Oklahoma 73105.

The office of the commissioner is the agency
which issues Oklahoma physicians their nar-
cotics and controlled substances permits. The
commission is a part of the Attorney General’s
office, however, it has a separate law that con-
trols it.

The Jim Thorpe Office Building is located to
the south and west of the State Capitol Build-
ing in the State Capitol complex. □

HEALTH CARE MANAGEMENT

MASSES OF PAPERWORK AND SLOW RECEIVABLES
. . . these two enemies are overwhelming todays Medical
Office! How to deal with these two is the “number one
business problem” for many doctors.

In DIRECT RESPONSE to THESE PROBLEMS and
related business needs of the Physician, HCM, with
YEARS of EXPERIENCE in MEDICAL BILLING and
COMPUTER OPERATIONS, has developed a TOTAL
SYSTEM for Physician’s Billing and Accounts
Receivable Management.

HCM's system is simple, easy to learn, requires no
special equipment, is flexible, and can follow along the
lines of your present business office procedures.

For further information, contact:
Gene Highfill

Academy Computing Corporation
3535 NW 58th — Suite 102
Oklahoma City, Oklahoma 73112
405/947-7746

Journal / March 1975 / Volume 68

DOCTOR, WHAT WILL YOU EARN?

It depends, of course, on your age and annual earnings, but the amount can quite reasonably
exceed $400,000.

Is this logical? Not when you can participate in the . . .

O.S.M.A. GROUP DISABILITY INCOME PROGRAM

Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION
. . . gives you individual coverage at low group rates.

. . . offers flexible waiting periods at your option.

. . . guarantees you an income when you are disabled from an accident or sickness.

. . . offers optional Indemnity from $200.00 to $2,500.00 per month.

. . . pays for lifetime on accident and up to age 65 on sickness.

For Additional Information, call or write

Jim Thaxton, Bill Howard or Rodman A. Prates
C. L. PRATES & COMPANY, INC.

720 N.W. 50th P.O.Box 18695
OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848=7661

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance
Springfield, Mass.

For additional details and application form, please contact

Jim Thaxton

Administrator

720 N.W. 50th Telephone 405 848-7661

P-O. Box 1 8593 Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

Oklahoma State Medical Association

National Malpractice
Situation Deteriorating

While Oklahoma physicians are enjoying no
difficulty with their professional liability in-
surance programs, the national picture is
bleak and deteriorating rapidly. Many physi-
cians throughout the country find it impossible
to purchase malpractice coverage at any price.

Professional liability is heating up as a key
issue in Congress this year. Among the several
professional liability proposals being intro-
duced, the most recent is by Senator Kennedy
of Massachusetts.

Kennedy’s proposal, the National Medical
Malpractice Insurance and Arbitration Act of
1975, would authorize the Secretary of HEW to
contract with "providers of health care ser-
vices” who choose to participate in the pro-
gram. The providers would pay an annual
premium to a medical malpractice firm and
would receive federal medical malpractice
coverage. In return for participation, providers
would be required to comply with state license
and relicense requirements which meet or ex-
ceed minimum standards established by the
Secretary of HEW.

Participating physicians would also agree to
accept review of their services by PSRO’s, to
accept as payment in full for Medicare cases
the level of payment established by the federal
government and to obtain concurring opinions
from a specialist prior to performance of surgi-
cal procedures.

The Kennedy bill also would require mal-
practice claimants and medical care providers
to submit medical malpractice disputes to
non-binding arbitration. The claimant could
either accept the decision of the Arbitration
Panel or institute court actions. The decision of
the Arbitration Panel, however, would be ad-
missible as evidence in court.

Senate Bill 188, by Senator Gaylord Nelson
of Wisconsin, would authorize the Health,
Education, and Welfare Department to set up a
reinsurance program and to conduct studies
and experiments in professional liability
coverage.

Representative James Hastings of New
York, a member of the House Health Subcom-
mittee, announced that a National Conference
on Medical Malpractice Insurance would be
held in Washington, DC, March 20th-21st.
The two-day conference was arranged by Hast-

ings and the American Group Practice Associ-
ation.

While Congressional interest was increas-
ing, a number of professional liability insur-
ance companies announced they were either
leaving the field, or making drastic changes in
their plans.

The St. Paul Fire and Marine Insurance
Company, one of the nation’s largest profes-
sional liability writers, announced that it was
beginning to write all policies on a "claims-
made” contract basis. Shortly after the an-
nouncement, the American Medical News
reported that "reaction to the news by mem-
bers of the medical and insurance professions
has varied from intense opposition to cautious
endorsement. None viewed the action as any-
thing more than a temporary solution to a vast
problem. Some, fearing it will become a trend,
saw it as a real danger to the practice of
medicine.”

The company explains "claims-made” in the
following way: "Claims-made is a professional
liability policy that provides coverage for
claims reported to (the company) during the
12-month term of the policy. Next year’s claims
are covered by next year’s policy. Professional
services covered are those rendered during the
policy period or any previous periods during
which the doctor was insured by (the company)
under a claims-made policy.”

In their company publication, Malpractice
Digest, St. Paul offered this example of how
claims-made would work: Until 1975 Doctor X
has been insured under an occurrence contract.
Thus, claims reported anytime resulting from
professional acts rendered up to 1975 are co-
vered under those occurrence policies.

"On March 1st, 1975, the doctor buys the St.
Paul’s Claims-made Policy. Any claims re-
ported from March 1st, 1975, to March 1st,
1976, that resulted from a professional act
rendered during that period would be covered.
It is not necessary the claims be settled before
March 1st, 1976, only that the claim (or an
incident the doctor has reason to believe may
lead to a claim) be reported by that date.

"As time goes on, Doctor X continues to carry
claims-made coverage. The retroactive date
remains March 1st, 1975. Any claims reported
resulting from a professional act on or after
March 1st, 1975, will be covered by the
claims-made policy in force (in the year) when
the claim is made.”

Journal / March 1975 / Volume 68

news

As long as a physician keeps the claims-
made policy in force he is protected against all
claims. The major disadvantage to the indi-
vidual physician in this new type of profes-
sional liability coverage is that he must con-
tinue to carry the policy even after he termi-
nates his practice of medicine. If he moves out
of the state where the policy is written, be-
comes disabled, retires or otherwise interrupts
his practice, he will be forced to continue carry-
ing coverage in the state where he originally
purchased the claims-made policy.

On another front, the American Medical As-
sociation has prepared and distributed a pack-
age of proposed remedial legislation aimed at
resolving the malpractice problem. The pack-
age has been distributed to all medical associa-
tions by the AMA’s Office of General Council.

The suggested legislative approaches are in
line with the AMA Board of Trustees three-
point Statement on Professional Liability is-
sued in January.

The American Medical News reported the
following actions being called for by the AMA
Board:

"Establishment of a voluntary joint under-
writers association in each state to spread the
risk of insurance coverage among all liability
carriers.

"Passage of bills to limit awards for pain and
suffering, place a ceiling on awards, shorten
statutes of limitations, seek sliding conting-
ency fee scales, limit the guaranty of medical
results to assurances set forth in writing, and
to eliminate injury alone as a basis of negli-
gence.

"Creation, with the cooperative effort of the
AMA and other groups, of a workmen’s com-
pensation type of program.”

The OSMA’s Legislative Committee is
studying the recommendations from the
AMA’s Office of General Council to determine
if any of them are applicable to Oklahoma’s
present situation.

While the professional liability situation
was of grave concern to the medical profession,
it was of no real concern to the general public.
However, when physicians began to threaten
to quit practicing medicine because of the high
cost of professional liability insurance, it be-
came a public crisis. Newspapers throughout
the United States have reported on and then
editorialized about the malpractice situation.

While concern is high, and numerous "solu-
tions” are being offered, many physicians and
lawyers who have studied the situation are
urging that ". . . we procede with great cau-
tion. This is truly a case where the cure may be
worse than the disease.”

It has been pointed out by observers that this
problem revolves around two of the world’s
great professions, medicine and law. Tamper-
ing with either, and especially with both, can
have far reaching consequences. □

Hawaii Tour In November
Filling Rapidly

The OSMA tour to Hawaii set for next
November is already filling rapidly. The tour
will correspond with the AMA’s 1975 Clinical
Session in Honolulu November 30th-December
5th, 1975. It gives physicians an opportunity to
combine business and pleasure.

The OSMA’s tour will leave Oklahoma City
November 28th and return December 7th. It
will feature ten days and nine nights including
seven nights of superior room accommodations
at the beautiful Hawaii Regent Hotel on
Waikiki and two nights at the magnificent
Maui Surf JTotel on the valley island of Maui.
Package price is $595 per person for a deluxe
room accommodation (double occupancy) or
$575 for a superior room accommodation (dou-
ble occupancy).

An optional tour, in place of the two nights
at the Maui Surf Hotel, is available for a $51
surcharge to the Mauna Kea Hotel, considered
to be one of the most luxurious in the world. It
is located on the "big” island of Hawaii.

The tour price includes round-trip jet
economy airfare from Oklahoma City to Hon-
olulu via Braniff 747 and the inter-island air-
fare necessary for the two-day side trip. All
baggage handling tips on arrival and depar-
ture in Honolulu and Maui are covered along
with hotel portage and the constant avail-
ability of an experienced tour guide or director
to assist travelers.

A $75 deposit per person is required to hold
places on the tour. Persons interested should
send their reservations to the Oklahoma State
Medical Association, 601 Northwest Express-
way, Oklahoma City, Oklahoma 73118, atten-
tion: Don Blair.

A color brochure describing the OSMA tour
is being distributed to all Oklahoma
physicians. □

Oklahoma State Medical Association

BEVERLY HILLS HOSPITAL
BEVERLY HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

PSYCHIATRY

Jackson H. Speegle, MD
John T. Holbrook, MD

Fred H. Jordan, MD
Joseph H. Lindsay, MD

PSYCHOLOGY

George R. Mount, PhD Tom I. Payton, MS

Donald L. Whaley, PhD Patrick R. Barnes, MS

EDUCATION DIRECTOR

William E. Nix, PhD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND R.T. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

Journal / March 1975 / Volume 68

news

Utilization Review Regulations
Stir Controversy and Concern

New regulations requiring certification of all
Medicare and Medicaid hospital admissions
within 24 hours became effective February 1st.
Published by the Health, Education, and Wel-
fare Department in early December, the new
regulations immediately drew opposition from
small hospitals throughout the United States,
and especially in Oklahoma.

All Medicare and Medicaid hospital admis-
sions are to be certified as medically necessary
within one working day of the initial admis-
sion and assigned a target length of stay. This
length of stay is to be based on the fiftieth per-
centile of average length of stay by diagnosis
and patient age.

The initial certification may be done by a lay
person known as a nurse coordinator, patient
care coordinator, or Utilization Review Coor-
dinator. This person, working from a set of
criteria or guidelines developed by each hospi-
tal, may certify an admission as medically
necessary if the admitting documents contain
sufficient justification. In the event there is not
enough information, the coordinator must take
the questioned admission to the Chairman of
the Utilization Review Committee, or his de-
signee, for a determination.

The coordinator may not deny a certification,
they can only certify. Denial of certification
can only be done by a physician.

In the event that an admission is denied by
the Utilization Review physician, then the
admitting physician may appeal to the Utiliza-
tion Review Committee.

At the present time Oklahoma has over 50
hospitals with four or fewer physicians on the
staffs. These hospitals are concerned that it
would be "numerically” impossible for them to
meet the requirements of the new Utilization
Review Regulations. The regulations require
that the physician-reviewers must be dis-
interested in the case. In the smaller hospitals,
this requirement would eliminate almost every
physician on the staff. It is not uncommon, in
smaller communities, for each physician to be
covering for every other physician.

Because of the possibility that the new
Utilization Review Regulations could result in

the smaller hospitals being eliminated from
payment by Medicare and Medicaid, numerous
protests began to be heard throughout the
United States. In Oklahoma, medical and farm
groups, chambers of commerce, and other in-
terested organizations began to complain to
their congressmen and to HEW.

Representatives David Craighead of Mid-
west City and Tom Stephenson of Watonga
conducted a public hearing on the problem at
the Oklahoma State Capitol Building Feb-
ruary 19th. Another hearing was conducted
the following Friday in the Federal Building in
Oklahoma City by United States Senators
Bartlett and Bellmon.

Numerous persons testified at both hearings
to the effect that the small hospitals could not
meet the new Utilization Review require-
ments. Not only was there difficulty in provid-
ing the appropriate number of "disinterested”
physicians, there was also a problem in finding
a registered nurse to serve as the coordinator.
Many of the small hospitals throughout the
state cannot procure enough registered nurses
to meet the requirements of the hospital licen-
sure laws. The new Utilization Review Regula-
tions, although not specifying a registered
nurse, have such stringent requirements on
the coordinator as to almost require that it be
such a licensed person.

Aside from the problem of finding an appro-
priate person to serve as a coordinator, the
small hospitals pointed out that this required
adding a whole new position to their hospital
staff, thus increasing their cost of doing busi-
ness.

In each of the hearings the Oklahoma State
Medical Association testified to the effect that
they did not like the new regulations, but
would work with the hospitals to see if it was
possible to implement them. In the event im-
plementation was not possible, the OSMA pro-
posed that small hospitals, those with active
staffs of only a few physicians, be granted a
waiver by the Secretary of HEW and then re-
quired to follow guidelines similar to the old
Utilization Review requirements. The net ef-
fect would require the small hospitals to do re-
spective review, as opposed to concurrent re-
view and certification.

In order to assist the small hospitals, the
OSMA, through its Oklahoma Foundation For
Peer Review, Inc., had established a Task
Force on the new Utilization Review Regula-

Oklahoma State Medical Association

tions. The Task Force consisted of representa-
tives from the OSMA, Oklahoma Osteopathic
Association, Oklahoma Nursing Home
Association, Oklahoma Hospital Association,
the Licensing Division of the State Health De-
partment, the Part A Carrier, Part B Carrier,
and the Welfare Department. The Task Force
purpose was to keep each organization as in-
formed as possible on the changing situation
regarding the new regulations. In addition, the
Task Force sponsored a series of five work-
shops to assist hospitals in implementing, if
possible, the UR Regulations.

The five workshops were held in McAlester,
Tulsa, Oklahoma City, Alva, and Altus. Each
workshop lasted a full-day and covered topics
such as the new Utilization Review Plan Re-
quirements for Hospitals, the Utilization Re-
view Procedure Manual, and what Medicare
and Medicaid expected from the Utilization
Review Committees.

For its part, the OSMA, through the Okla-
homa Foundation for Peer Review, Inc., pub-
lished a "Guidelines For Hospital Care” hand-
book. The handbook contains information on
admission criteria and length of stay. It was
immediately distributed to all Medicare cer-

tified hospitals in the state of Oklahoma.

The handbook contains admitting criteria
and length of stay information on 106 admit-
ting diagnoses. Under each diagnosis is also
listed the most common reasons for possible ex-
tensions of lengths of stay.

The criteria length of stay were adopted by
the Oklahoma Foundation For Peer Review,
Inc., from those developed and published by the
Mississippi State Medical Association and the
Mississippi Regional Medical Program. The
lengths of stay listed in the handbook are
based on the Professional Activities Study,
PAS, statistics for southern states.

The foreword to the handbook states that the
guidelines, in no way. . ."represent a manda-
tory pattern of practice to which all physicians
must conform. They are general guidelines. In
any specific case, a physician may deviate from
them on the basis of his professional judgment.
Such deviation does not necessarily imply in-
adequate medical care.”

The foundation will conduct periodic reviews
and revisions of the handbook to insure that
the criteria and length of stay information re-
flect existing medical skills, knowledge, and
quality hospital care in Oklahoma. □

Offering complete private Psy-
chiatric Services using the
Therapeutic Community ap-
proach in an open setting.

Fully Accrediated
60 Beds

Mrs. Billie Speck-Administrator

MEDiCENTER PSYCHIATRIC
HOSPITAL

1505 Eighth Wichita Falls, Texas 76301

Services Available

• Psychotherapy Individual and Group

• Chemotherapy

• Recreational Therapy

• Occupational Therapy

• Psychological Testing

• Psychiatric Social Worker Services

• Neurological Consultation

• Electro-Convulsive Therapy
0 Clinical Laboratory
0 X-ray

• Pharmacy

• Physical Therapy
0 Medical Consultations

Journal / March 1975 / Volume 68

news

National Health Insurance
Guidelines Issued By AMA

Guidelines or principles regarding National
Health Insurance have been endorsed by the
Board of Trustees of the American Medical
Association. The guidelines were given the
widest possible distribution.

They were adopted by the AMA’s Board of
Trustees during its regular meeting in Chicago
on October 25th — 26th, 1974. The same guide-
lines were reiterated during the AMA’s Clinic-
al Meeting in Portland, Oregon in late Novem-
ber and early December.

Fourteen points are included in the guide-
lines to cover those areas that the AMA feels
are essential for National Health Insurance.

The very first point best sums up the AMA’s
entire position: "Minimum federal involve-
ment in administration of any National Health
Insurance Program.”

The guidelines go on as follows:

(2) State jurisdiction with respect to licen-
sure and certification of professional health
personnel and regulation of insurance.

(3) Minimum federal dollars in financing of

programs for comprehensive coverage at least
possible costs.

(4) Funding through federal, state and pri-
vate funds including employer-employee
contributions for private health insurance and
an individual tax credit as applied for full
health care protection.

(5) No added Social Security tax for financ-
ing.

(6) No administration by Social Security.

(7) Cost sharing by participating individ-
uals and families and a subsidy for the indi-
gent scaled according to income.

(8) Use of private insurance on risks and
underwriting basis.

(9) Comprehensive coverage, basic and
catastrophic, for the entire population.

(10) Pluralism in methods of health care de-
livery.

(11) Cost controls as appropriate.

(12) Quality controls as appropriate.

(13) Continuity of benefits.

(14) Coordination of benefits.

The fourteen points establish both the
minimums and the maximums that the AMA
feel are necessary in any National Health In-
surance Program. □

SPONSORED BYTHE OSMA

Washington National Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE
DISABILITY INCOME INSURANCE

Contact Association Counselors:

Jim Thaxton, Bill Howard or Rodman A. Prates

Administrators

720 NW 50th

PO Box 1 8593 405 842-3735 Oklahoma City 73118

100

Oklahoma State Medical Association

Balkan Tour Combines
Business and Pleasure

A two- week tour to the Balkan’s offers Okla-
homa physicians an opportunity to combine
business and pleasure. The tour, being spon-
sored by the Oklahoma State Medical Associa-
tion, offers two weeks in Bucharest, Istanbul,
and Dubrovnik. It will depart Oklahoma City
July 19th.

The cost of this non-regimented, luxury trip,
which includes direct flights on chartered jets,
accommodations at deluxe hotels, complete
American breakfasts and gourmet dinners at a
choice of the finest restaurants, is only $1,128
per person.

Arrangements for the trip have been made
for the OSMA by INTRAV, the travel company
that has spent years developing deluxe person-
alized vacations at charter cost savings.

Exclusive features of the Balkan tour in-
clude VIP pre-registration at all hotels; ex-
pedited customs formalities; a generous 70
pound baggage allowance; a travel director and
five hosts in each city to assist the traveler;
optional sightseeing tours; optional side trips
to Kiev in Russia and Izmir in Turkey; and
plenty of time for shopping and relaxing.

Combined with the fun of the trip will be a
medical seminar for all physicians. The semi-
nars will be conducted in each of the three
major cities on the tour. Upon completion of
the seminars, a Certificate of Attendance will
be issued to each participating physician. The
certificate will show an outline of all meetings
held with names of lecturers, and topics dis-
cussed.

During the Bucharest seminar topics will in-
clude Health Care Delivery Services in
Rumania, Administrative Problems Related to
Old Age, Obstetrical Emergencies, and Eu-
trophic Therapy In Geriatrics-Therapy With
Procainegerovital H-3.

Topics for Istanbul include Abdominal Sur-
gery and Peripheral Vascular Diseases, New
Methods in Cardiovascular Research, Gyne-
cological and Obstetrical Care in Istanbul,
Population Planning Activities, Major Ortho-
pedic Problems in Turkey, Private Practice
and Health Care in Turkey, and Neuro-
physiology and Clinical Electroencephalo-
graphy.

During the Dubrovnik stay topics will in-
clude discussions on Radiology, Prevalence of
Rickettsial Disease Incidence of Viral Hepati-

Journal / March 1975 / Volume 68

tis, Curative Aspects of Medicine, Narcotic and
Non-narcotic Analgesics, Isolated Organs with
their Nerves as Tools in Experimental Medi-
cine, and Gastrointestinal Medicine.

The faculty for each of the seminars is made
up of physicians from the country being visited
and acknowledged experts from the United
States. Members of the faculties have been
carefully selected in each country to provide
interesting information. Registration for the
Medical Seminar is $45 per person.

Mixed with the business of the seminar, of
course, is the fun of travel. Bargain hunters
will find a wealth of trinkets and treasures;
antiques, wood carvings, jewelry, em-
broideries, copper and brass lamps and kettles,
Bursa silks, leathers, hubbly-bubbly pipes and
Oriental rugs.

Mosques and cathedrals, museums and art
galleries, sun and sea, are there to be discov-
ered. Tastefully prepared foreign foods are in
abundance. Try Sarmale, a Rumanian dish of
spicy meat wrapped in cabbage leaves, or the
Turkish shish kebob with a glass of beer.

In Yugoslavia one whole island, dominated
by a Benedictine Abbey, has been converted for
tourist entertainment. Dinner in the Abbey it-
self is considered a gourmet delight.

Persons wishing to register for the Balkan
tour should contact the Oklahoma State Medi-
cal Association, 601 Northwest Expressway,
Oklahoma City, Oklahoma 73118. A $100 per
person deposit is required. □

Health Benefits for the Unemployed

Although President Ford urges no new
federal spending programs, interest in
providing health benefits for the unemployed
has generated several congressional proposals.

The first proposal was introduced by Senator
Bentsen of Texas. Citing rising unemployment
rates, he called for the temporary extension of
Part A Medicare benefits to unemployed
workers currently entitled to unemployment
benefits. Under his proposal, Senate Bill 496,
hospital benefits would also be provided to a
dependent spouse or dependent child of an
unemployed worker.

In commenting upon the introduction of his
bill, Bentsen noted that some 6.5 million men
and women are now out of work and that
government estimates indicate that more than
1.74 million workers have lost their

101

news

hospitalization coverage since December of
1973.

Bentsen estimates that the 12-month cost of
his program would be $2.1 billion. General
revenues would be appropriated to the Part A
Trust Fund to pay for the temporary
hospitalization insurance program, and
existing Medicare deductibles and
co-payments would be applicable to newly
covered individuals.

Bentsen’s bill had barely gotten warm before
Senator Kennedy got in the act. He rushed in
to introduce Senate Bill 625, the Emergency
Unemployment Health Benefits Act of 1975.

Kennedy’s measure would amend the
Emergency Jobs and Unemployment
Assistance Act of 1974 so that unemployed
individuals entitled to benefits under state or
federal unemployment plans would have their
health insurance premiums paid by the federal
government.

Under the Kennedy proposal unemployed
individuals would be entitled to health
insurance benefits of the type and scope which
they would have received under their previous
employment agreement. The Secretary of Labor
would make arrangements to pay insurance
carriers or other appropriate parties for the
continuation of the unemployed workers
health insurance. State unemployment
compensation agencies would certify
individuals as being eligible for health
insurance benefits.

Cost estimates on the Kennedy proposal
range between $1 and $1.5 billion assuming an
unemployment rate of 8 per cent. The program
would expire on June 30th, 1976.

Both Senators Bentsen and Kennedy, in
commenting on their new bills, called for early
adoption of a Comprehensive National Health
Insurance Program. □

St. John’s Hospital Offers Expanded
Medical Education Program

An expanded program of medical education
available to interested paramedical personnel,
as well as licensed physicians, has been sche-
duled by St. John’s Hospital in Tulsa. Eight
sessions per year have been set up by the
hospital’s Department of Continuing Medical
Education, under the direction of Bryce O.

102

Bliss, MD. Each session is sponsored by a dif-
ferent section of the hospital’s medical staff.

The first session was held February 10th and
was on the subject of joint replacement
surgery. The second program in the series was
March 10th and stressed the subject of cardio-
vascular disease.

Announcement of the expansion of the
hospital’s educational service was made at St.
John’s General Staff meeting held in January.
R. E. McDowell, MD, Chief of Staff, stated,
"This the first time this interchange of know-
ledge on updated procedures and treatment for
particular specialties has been made available
regularly to all other interested medical and
allied personnel throughout the area on such a
wide scale. We urge support of this program,
and believe it will serve to keep the Tulsa med-
ical community informed as to the latest pro-
cedures in the various specialties.”

Personnel throughout northeastern Okla-
homa and neighboring states are invited to at-
tend the meetings, which will be held in St.
John’s Hospital School of Nursing Auditorium
from 7:30 to 9:30 pm. Free parking is available
for attendees in the adjoining 19th Street
parkade.

Future programs and topics to be covered
and dates scheduled are: April 14th, Cancer
Treatment; June 9th, Medicine; July 14th,
Pediatrics; August 11th, Ophthalmology; Oc-
tober 13th, Pathology; and December 8th,
Surgery.

The success of the first two programs have
encouraged the hospital to begin planning for
the 1976 sessions. They have already sche-
duled sessions on Anesthesiology, Radio-
therapy, Ob-Gyn, Dermatology, Psychiatry,
ENT, Emergency Room Procedures, and
Urology. □

Mark Your Calendar

Now!

Oklahoma Medical Summmit 75

April 23rd-26th, 1975
Lincoln Plaza Forum
Oklahoma City

Oklahoma State Medical Association

Book Reviews

Spinal Dysraphism. Spina Bifida Occulta.

By C. C. Michael James and L. P. Lassman,
144 pp, Appleton-Century-Crofts, London,
1972.

This monograph deals with those congenital
malformations of the neural tube which are
hidden and quite unlike the more familiar
myelomeningocele. They include dermal sinus,
dermoid cyst, intraspinal lipoma, and
diastematomyelia. A detailed description is
provided of the embryology, pathology, clinical
presentation, radiologic findings and thera-
peutic principles. Two-thirds of the book is de-
voted to analysis of 100 cases which provides
the reader with a good idea of the range of ab-
normalities.

This monograph is concerned almost ex-
clusively with the author’s own experience and
makes little reference to the work of others.
Some of the illustrations are good and others
are poorly produced.

This book will have limited interest to most
physicians, but will serve as a useful reference
to those concerned with such defects. Harris D.
Riley, Jr., MD

Communicable Infectious Diseases.
Seventh Edition. By Franklin H. Top, Sr., MD,
and Paul F. Wehrle, MD, 803 pp. C. V. Mosby
Co., St. Louis, 1972.

This book originally edited by Top has been a
major and popular text in the field of infectious
diseases for more than a third of a century
since its first edition in 1931. The new co-
editor, Paul Wehrle, and the 25 new well-
qualified contributors, have brought the scien-
tific and epidemiologic knowledge of their sub-
ject matter up to date while maintaining the
scholarly and historical viewpoints. It contains
five additional chapters since the last edition
but with an increase of only 75 pages making it
clear that a large proportion of the book has
been completely rewritten by the new contri-
butors. This edition is dedicated to Alexander
D. Langmuir, formerly Chief of the Epidemiol-
ogy Branch of the Center for Disease Control.

This edition can be recommended for all con-
cerned with infectious diseases as an
authoritative presentation of the problem.
Harris D. Riley, Jr., MD □

Miscellaneous Advertisements

BURROUGHS 1500 POSTING MACHINE
with typewriter, completely programmed for
itemization of medical bills. Can also do ac-
counts payable. Also, Burroughs series 50
posting machine programmed for itemization of
medical bills. Write or call Mr. Joe Crosthwait,
MD, 7221 East Reno, Midwest City, Oklahoma
or 405 737-4405.

WILL BUY X-RAY FILMS, LEAD AND
HOSPITAL equipment. Finders fee available.
Sick room rentals. BUY — SELL — TRADE.
C. E. Clancy, 634-0111.

WANTED: FULL-TIME OCCUPATIONAL
PHYSICIAN for permanent employment in
Remington Arms Company plant in Indepen-
dence, Missouri. Excellent opportunity. Gen-
eral practice background acceptable. Excellent
salary and outstanding company-paid benefit
program. An equal opportunity employer M/F
Write or call A. Travostine, Plant Manager,
Remington Arms Company, Inc., Lake City
Army Ammunition Plant, Independence, Mis-
souri 64050, 816 796-7101. □

Journal / March 1975 / Volume 68

103

INTERNAL MEDICINE

REVIEW COURSE

1975

East Lecture Hall

Basic Science Education Building
University of Oklahoma College of Medicine
Oklahoma City, Oklahoma

Developed by

The Department of Medicine
University of Oklahoma Health
Sciences Center

and

Office of Continuing Medical
Education for Physicians

Registration Fee;

$15.00 per semester

Send Advance Registration to: Office of
Continuing Medical Education for Physicians,
University of Oklahoma Health Sciences
Center, P.O. Box 26901, Oklahoma City,
Oklahoma 73190

DATE TITLE — SPEAKER

March 19, Gastroenterology I — Gastroenterology
Section

March 26, Congenital Heart Disease In The Adult-
— Lofty L. Basta, MD

April 2, ASCVD and Cardiomyopathies — Stephen D.
Shappell, MD

April 9, Gastroenterology II — Gastroenterology Sec-
tion

April 16, Metabolic Disorders Presenting In The
Adult — Sylvia Bottomley, MD

April 23, Pituitary Adrenalin and Endocrine
Hypertension — David C. Kem, MD

April 30, Thyroids and Gonads — E. William Allen,
MD

Rondomyci

(methacycline HCI)

CONTRAINDICATIONS: Hypersensitivity to any of the tetracyclines.
WARNINGSrTetracycline usage during tooth development (last half of pregnan
years) may cause permanent tooth discoloration (yellow-gray-brown), whici
common during long-term use but has occurred after repeated short-ternr ;
Enamel hypoplasia has also been reported. Tetracyclines should not be used
group unless other drugs are not likely to be effective or are contra
Usage in pregnancy. (See above WARNINGS about use during tooth devi
Animal studies indicate that tetracyclines cross the placenta and can be toxic
veloping fetus (often related to retardation of skeletal development). Embryotc
also been noted in animals treated early in pregnancy.

Usage in newborns, infants, and children. (See above WARNINGS about i
tooth development.)

All tetracyclines form a stable calcium complex in any bone-forming tissue. I j
in fibula growth rate observed in prematures given oral tetracycline 25 mg/I
hours was reversible when drug was discontinued.

Tetracyclines are present in milk of lactating women taking tetracyclines.

To avoid excess systemic accumulation and liver toxicity in patients with imp
function, reduce usual total dosage and, if therapy is prolonged, consider serur
terminations of drug. The anti-anabolic action of tetracyclines may increase B
not a problem in normal renal function, in patients with significantly impaired
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and
Photosensitivity manifested by exaggerated sunburn reaction has occurred
cyclines. Patients apt to be exposed to direct sunlight or ultraviolet light shoulc
vised, and treatment should be discontinued at first evidence of skin erythema.
PRECAUTIONS: If superinfection occurs due to overgrowth of nonsusceptible o
including fungi, discontinue antibiotic and start appropriate therapy.

In venereal disease, when coexistent syphilis is suspected, perform darkfiiji
nation before therapy, and serologically test for syphilis monthly for at least fou
Tetracyclines have been shown to depress plasma prothrombin activity; patie
ticoagulant therapy may require downward adjustment of their anticoagulant do
In long-term therapy, perform periodic organ system evaluations (include
renal, hepatic).

Treat all Group A beta-hemolytic streptococcal infections for at least 10 days.
Since bacteriostatic drugs may interfere with the bactericidal action of pemc
giving tetracycline with penicillin.

ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms): anorexi;
vomiting, diarrhea, glossitis, dysphagia, enterocolitis, inflammatory lesions (w
ial overgrowth) in the anogenital region

Skin: maculopapular and erythematous rashes; exfoliative dermatitis (uncomn
tosensitivity is discussed above (See WARNINGS).

Renal toxicity: rise in BUN, apparently dose related (See WARNINGS).
Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoic
pericarditis, exacerbation of systemic lupus erythematosus.

Bulging fontanels, reported in young infants after full therapeutic dosage, h
peared rapidly when drug was discontinued.

Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosinophilia.

Over prolonged periods, tetracyclines have been reported to produce brown,
croscopic discoloration of thyroid glands; no abnormalities of thyroid function s
known to occur.

USUAL DOSAGE: Adults- 600 mg daily, divided into two or four equally spac
More severe infections: an initial dose of 300 mg followed by 150 mg every si:
300 mg every 12 hours. Gonorrhea: In uncomplicated gonorrhea, when penici
traindicated, ‘Rondomycin’ (methacycline HCI) may be used for treating both
females in the following clinical dosage schedule: 900 mg initially, followed t
q i d fora total of 5.4 grams.

For treatment of syphilis, when penicillin is contraindicated, a total of 18 to 2-
'Rondomycin' (methacycline HCI) in equally divided doses over a period of i
should be given. Close follow-up, including laboratory tests, is recommended.

Eaton Agent pneumonia: 900 mg daily for six days.

Children - 3 to 6 mg/lb/day divided into two to four equally spaced doses.

Therapy should be continued for at least 24-48 hours after symptoms and
subsided

Concomitant therapy: Antacids containing aluminum, calcium or magnesium
sorption and are contraindicated. Food and some dairy products also interfere,
one hour before or two hours after meals. Pediatric oral dosage forms sho1
given with milk formulas and should be given at least one hour prior to feeding.

In patients with renal impairment (see WARNINGS) , total dosage should be
by reducing recommended individual doses or by extending time interval
doses

In streptococcal infections, a therapeutic dose should be given for at least 10
SUPPLIED: Rondomycin' (methacycline HCI): 150 mg and 300 mg capsules;
taining 75 mg/5 cc methacycline HCI.

Before prescribing, consult package circular or latest PDR information.

-ste

kffi WALLACE LABORATORIES

CRAN BURY, NEW JERSEY 08512

104

Oklahoma State Medical Association

One of the objectives of the auxiliary is to
assist the medical association in its program to
improve the quality of life through health edu-
cation and service. The auxiliary’s Community
Health Committee strives to help its units
make this objective a reality. We think of its
role as an opportunity to help identify health
problems in the community, to help identify
health resources and to stimulate solutions to
health problems through public education and
volunteer services. Our Community Health
programs and projects fall into two broad cate-
gories: prevention and care.

As a member of the Community Health
Team for the Auxiliary to the Oklahoma State
Medical Association, I attended the Southern
Regional Workshop in New Orleans last Oc-
tober. In small informal sessions we had the
opportunity to exchange ideas with other state
Community Health Chairmen. We found the
local units in each state, like individuals,
unique and varied in their interests and
accomplishments but all working to improve
the quality of life through education and ser-
vice. As a group we agreed our greatest prob-
lem is lack of communication and I appreciate
the comments and suggestions presented to us
in this column last month.

During our workshop we discussed some of
the basic steps and principles which apply to
virtually every program and project an aux-
iliary might undertake in Community Health.
These steps include:

1. A survey of your community to find out
what the needs are and what resources are
available.

2. Establish priorities for meeting the most
pressing Community Health needs.

3. Consult your medical society advisory
committee.

4. Enlist the cooperation and help of other
concerned groups and individuals in the com-
munity.

5. Set goals.

6. Evaluate your program.

7. Report your programs and projects to your
state Community Health Chairman and medi-
cal society.

In one of our workshop sessions each Com-
munity Health Chairman gave a report on a
successful project from her home state. I was
proud to announce the National Award one of
our local units (Tulsa County) had just re-
ceived from The Woman’s Conference of the
National Safety Council for their work with a
poison control project. Our National Commun-
ity Health Chairman, Mrs. C. H. Gilliland, was
in Chicago and present when this award was
presented. She gave an impressive report for
Oklahoma and urged other auxiliaries to com-
pete for this award in the future.

The final workshop session was spent going
through the package programs and kits. These
program aids were developed by the Woman’s
Auxiliary to the American Medical Association
to assist us in planning and implementing pro-
grams related to community health needs.
Many of these program aids are being revised
and you will find the latest factual information
with guidelines to help you get your programs
and projects off the ground.

Report time is just around the corner and I
am looking forward to receiving a Community
Health report from each local unit in Okla-
homa. Jewell Coates, Community Health
Chairman to the Auxiliary of the Oklahoma
State Medical Association. □

Journal / March 1975 / Volume 68

xxv

the last word

The AMA will file a lawsuit to prevent im-
plementation of the National Health Planning
and Resources Development Act. The suit
will seek to have the law declared unconsti-
tutional as an unwarranted assumption of
state authority by the federal government.
The law, which replaces the present Com-
prehensive Health Planning Program and
Regional Medical Programs, creates a sys-
tem of Regional Health Systems Agencies
with local and state agencies developing and
implementing health plans under guidelines
prepared by HEW.

President Ford’s National Health Budget

went to Congress. For fiscal year 1976 it calls
for $4.5 billion for non-Medicare-Medicaid
programs, $500 million less than Congress
appropriated. The major cuts are in National
Institutes of Health Research and in Alcohol-
ism, Drug Abuse and Mental Health Programs.
The NHI Budget was set at $1.8 billion, com-
pared with $2 billion approved for fiscal year
1975. Alcoholism, Drug Abuse and Mental
Health Programs are budgeted at $702 mil-
lion, compared with $826 million approved
by Congress, PSRO is budgeted to get $50 mil-
lion, a $14 million increase. The Ford Ad-
ministration pointed out that it might have
to change the timetable for the formation of
PsRO because of the shortage of funds.

Rigid Medicare and Medicaid hospital
utilization review regulations published by
the Secretary of Health, Education and Welfare
on November 29th and effective February 1st
have already caused at least one Oklahoma
physician to curtail his small town medical
practice. Louis C. Belter, MD, the only medical
doctor in Fairview, has curtailed his practice in
this northwestern Oklahoma community be-
cause the new regulations "put us in violation of
the Oath of Hypocrates.” Belter has taken other
employment in Oklahoma City, but will try to

XXVI

maintain some office and hospital practice for
the present time.

The physician’s protest not only relates to the
federal regulations recently imposed but also to
the Professional Standards Review Organiza-
tion law now being imposed by Congress on the
nation’s physicians and hospitals.

OU Medical Alumni are reminded to circle
Thursday, April 24th, on their calendars. This
is the date that has been set aside during Okla-
homa Medical Summit ’75 for the alumni and
spouses to get together for a fun-filled evening
of "liberations, food, and entertainment”. En-
tertainment will be furnished by Jayne Jayroe,
former Miss Oklahoma and Miss America. De-
tails will be sent to all alumni.

Medix, the award winning TV program

produced by the Los Angeles County Medical
Association, has become a nationally
syndicated TV program. It will be broadcast on
KWTV, Channel 9, in Oklahoma City. The
30-minute weekly show is designed to increase
public awareness of health problems. It will be
sponsored nationally, and in Oklahoma, by
Burroughs Wellcome Company in conjunction
with local medical societies. The content of
each program is authenticated by a committee
of the Los Angeles County Medical Association
physicians. Currently 50 television stations,
servicing about 50% of the nation, are
planning to carry Medix.

The AMA is now involved in three separate
lawsuits in Federal Court. It is suing the
Health, Education, and Welfare to stop the en-
forcement of the new Utilization Review Reg-
ulations for hospitals, to stop the enactment of
the Maximum Allowable Cost Drug Reim-
bursement Program, and to stay implementa-
tion of the new Health Planning bill. The
AMA’s new "aggressive posture” is being met
with some enthusiam by physicians throughout
the United States. □

Oklahoma State Medical Association

April

1975

Vol. 68, No. 4

of th e Oklah oma StateMedical Association

EDITORIAL BOARD

MARK R. JOHNSON, MD
Editor-in-Chief

HARRIS D. RILEY, Jr., MD
Editor

CONTENTS

ROBERT G. TOMPKINS, MD
Editor

editorial

ERNEST LACHMAN, MD
Corresponding Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

The Hazards of Motorcycles
President’s Page

105

107

scientific

OFFICERS

JACK L RICHARDSON, MD
Resident

ROGER J. REID, MD
Vice-President

HAVEN W. MANKIN, MD
Secretary-Treasurer

STAFF

DON BLAIR
BusinessManager

LOUISE MARTIN
EditorialAssistant

SUBSCRIPTION TO THE PURNAL is included in
membership fees. Other subscriptions are
$6.50 per year or $1.00 per copy with each
request subject to approval of the Editorial
Board.

POSTMASTERS: Send all change of address
notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

Penicillin Allergy, James Freed, MD . . . 108

history of medicine

Hill of Mercy: Chimborazo Military Hospital, 1861-

1865, Ronald C. Curnutt, MEd . . . 113

News from the Oklahoma State Department of

Health ........ 125

annual meeting

Oklahoma Medical Summit ’75 .... 128

Index .......... 128

Officers and Trustees ...... 129

Summit Officials ....... 130

Digest of Events ....... 132

Technical Exhibitors ....... 135

Program ......... 137

Summit ’75 Entertainment ..... 142

Summit Superstar Luncheon Speakers . . . 143

Agenda, House of Delegates ..... 144

Photo Contest and Photography Seminar . . 144

Delegates and Alternates ...... 145

Woman’s Auxiliary ....... 147

news

Death .......... 150

Book Reviews ........ 150

Miscellaneous Advertisements ..... ix

Index to Advertisers ....... xxiv

iii

Jji

lllllliip

wBKk

Oklahoma State Medical Association

The Hazards of Motorcycles

One crisp, fall afternoon a 19-year-old boy
was carried into the emergency room of the hos-
pital where I was serving my internship. His
right leg was streaming blood from a laceration
where he had hit the pavement after being
thrown from his motorcycle. As I started to cut
away his trousers, his wallet, comb, and a silver
lighter fell out of the pocket onto the floor. The
nurse brought a paper bag to collect his belong-
ings, pausing for a moment to admire the en-
graved silver lighter.

I finished suturing the boy’s wounds and ad-
mitted him to the hospital for observation be-
cause of a head injury. The next day I retrieved
the bag and delivered it to his room. "You were
lucky this time," I told him. "Your wounds will
heal. But the chances of killing yourself the
next time you get on that motorcycle are pretty
good. If you are as smart as you look, you will
get rid of the cycle.”

The youth seemed unimpressed. "Tell you
what, doc," he said, fishing the silver lighter out
of the bag I had brought him, "If I get into
another accident, you can have this lighter.”

Two weeks later he was brought to the hospi-
tal, DOA. I’ve still got the lighter.

An increasing health problem in recent years
is the rising number of injuries and deaths that
have occurred as the result of accidents involv-
ing two-wheeled motor vehicles, chiefly motor-
cycles.

Since 1955 the number of motorcycle regis-
trations has risen steadily, with a 450% jump
from 1961-1971 when the total topped 3.3
million.1 This compares with an overall motor
vehicle increase of only 50%. On the average,
there is now one motorcycle for every 62 persons
in the United States. Many influences have
fueled the motorcycle boom — the scarcity and
cost of gasoline, a glut of small, inexpensive
cycles from Japan, improvement in the image of
the cyclist by such popular movies as EASY
RIDER, and, of course, the activities of stunt-
man, Evel Knievel. More and more people have
turned to two-wheeled vehicles for both recrea-
tion and economy. Police departments use cy-
cles for traffic control, couriers use cycles to
deliver parcels, and everyone from teenage boys
to grandmothers rides cycles just for fun.

The rapid rise in the number of registered
motorcycles in this country over the last decade
has been accompanied by an increase in the
number of fatal injuries to motorcyclists.

Deaths among drivers of motorcycles and their
passengers have more than tripled between
1961 and 1971. While motorcycles may be
economical to buy and operate, their true cost in
terms of injury and death is excessive. The Na-
tional Highway Traffic Safety Administration
reports that during 1973, more than 3,000
motorcycle drivers and passengers lost their
lives. This fatality rate was more than twice
that for drivers and occupants of other types of
motor vehicles. Calculated on the basis of the
number of miles driven, the motorcycle is the
most hazardous type of motor vehicle. The mor-
tality for motorcycle riders is about 20 deaths
per 100 million miles, five times greater than
the rate for drivers and passengers of other
types of vehicles.1

Besides the greater risk of being involved in
an accident, motorcyclists are also much more
likely to be injured if a mishap does occur. The
National Safety Council estimates that 90% of
all motorcycle accidents involve personal injury
or death, as opposed to nine per cent of all other
motor vehicle accidents.2 The design of a motor-
cycle offers little or no protection to its riders,
and the handlebars, windscreen, and pedals can
be potentially lethal. A study of motorcycle ac-
cidents in New York revealed that 39% of in-
jured motorcycle operators suffered multiple
injuries.3 One patient had six serious, primary
injuries and 19 major, directly-related second-
ary problems. He was operated on 12 times be-
fore he died.

Injuries resulting from a motorcycle accident
are usually much more severe than those sus-
tained in an automobile accident. The motor-
cyclist, unprotected by the frame of his vehicle,
is often catapulted against another vehicle, ob-
ject, or pavement.1 Furthermore, the risk to the
companion "riding tandem" is quite sub-
stantial. Earlier studies indicated that 50% of
accident victims sustained head injuries.4 This
figure has dropped to around 24%, probably due
to the use of helmets.5 Nevertheless, a helmet
cannot offer full protection and may give the
wearer a false sense of security. In fact, various
studies suggest that even at present as many as
two-thirds of the motorcycle fatalities result

Journal / April 1975 / Volume 68

105

editorial

from head injuries.1 Head injuries still account
for considerable morbidity among survivors, in-
cluding impairment of intellectual function,
paralysis, blindness, and convulsive disorders
secondary to permanent brain damage.

Not only does the design of a motorcycle fail to
offer protection, but it may also encourage driv-
ers to take chances. Passing on the right, riding
between two lanes of traffic, cutting in and out,
and riding in the blind spot of automobile driv-
ers have been cited as common practice among
many cyclists.6 Furthermore, the cyclist may be
unable to cope with instability on wet or icy
pavement or gravel, longer braking distance,
poor lighting at low speeds, and crowding by
other vehicles.

Not only is the cyclist’s visibility low, but
many motorists will not give the cyclist the
right of way even if they do see him. The New
York study found that when a motorcycle col-
lided with another vehicle at an intersection,
the other vehicle was at fault 75% of the time.3
At other locations, however, the motorcyclist
was twice as likely to be at fault. According to
police records, the majority of accidents were
due to a failure of the operator to obey the traffic
laws or to have the motorcycle under control.

One of the particularly tragic aspects of the
motorcycle story is that the majority of the acci-
dent victims are young people — children in
their teens and young adults. Nationally, about
two-thirds of the motorcycle fatalities occur in
the 15-24-year age group.1 This is cruel and
needless waste. These young people have sur-
vived the first hazardous period of their lives
and, in fact, are entering not only the safest

period, healthwise, during the life span, but
also the period of maximum productivity to so-
ciety. Many studies indicate that inexperience
and lack of skill are of greater importance in
motorcycle accidents than in automobile
accidents.1 Yet most beginner motorcyclists
usually teach themselves with only a few "tips”
from a friend or a dealer. Improved education
for motorcycle riding should clearly be carried
out in driver education courses, by the motorcy-
cle industry and by automobile associations
concerned with safety.

These grim statistics serve notice that motor-
cycle accidents have reached epidemic propor-
tions, particularly among young people. Rec-
ords for the first four months of 1974 show
a 30% increase over the same period of 1973.
Even if the victim escapes death, he is of-
ten physically and emotionally scarred for
life. Regardless of what precautions are taken,
motorcycle riding still carries a very significant
risk of serious injury or death. Harris D. Riley,
Jr., MD, Children s Memorial Hospital, Univer-
sity of Oklahoma Health Sciences Center, Ok-
lahoma City, Oklahoma □

ACKNOWLEDGEMENT

Appreciation is expressed to R. D. Welsh for assis-
tance in preparation.

REFERENCES

1. Motorcycle Accident Fatalities. Metropolitan Life Statistical Bulletin
54:9-11, 1973

2. National Safety Council: Motorcycle Facts. Chicago, National Safety Coun-
cil, Statistics Division, 1966

3. Clark, D. W., Morton, J. H. The Motorcycle Accident: A Growing Problem.
J. Trauma 11:230-237, 1971

4. Bothwell, P. W., Aberd, M. B. Motor-Cycle Accidents. Lancet 2:807-809,
1960

5. Dillihunt, R. C., Maltby, G. L., Drake, E. H. The increasing problem of
motorcycle accidents. JAMA 196:1045-1046, 1966

6. Exploratory Meeting on Motorcycle Safety Education. Division of Accident
Prevention of the US. Publ ic Health Service, Department of Health, Education,
and Welfare, 1966.

CERTIFICATION EXAMINATION

for

AMERICAN BOARD OF FAMILY PRACTICE

The American Board of Family Practice announces that it will give its next two-day written cer-
tification fexamination on November 1st-2nd, 1975. It will be held at five centers geographically dis-
tributed throughout the United States. Information regarding the examination may be ob-
tained by writing:

Nicholas J. Pisacano, MD, Secretary
American Board of Family Practice, Inc.

University of Kentucky Medical Center
Annex No. 2, Room 229
Lexington, Kentucky 40506

Please Note: It is necessary for each physician desiring to take the examination to file a completed
application with the Board office. Deadline for receipt of applications in this office is June 15th, 1975.

106

Oklahoma State Medical Association

My tenure in office as
President of this fine state
medical association is
rapidly drawing to a close
and this will be my last
communication to you on
this page. The year has
flown by, most likely due
to the fact that you have
kept me free of many idle
moments. I should like herewith to thank you
for the opportunity to serve you and for the fine
cooperation and support I have received
throughout the past many months. I am proud
of our membership and honored that you al-
lowed me to contribute in some small way to
our organization.

By the end of this month I shall be replaced
by a fine new president, Doctor Arnold Nelson
of Midwest City. To those of you who have not
had the pleasure of his acquaintance I highly
commend him to you as a sincere, intelligent,
dependable leader. I feel privileged to have
known him better this past year and consider
him a wonderful friend. I know that he will be
accorded the same loyal support given me and I
thank you for that.

During the past month our national organi-
zation did two things for which we should be
grateful: It recognized the critical problem that
exists in professional liability and it proceeded
with the legal action it filed in Federal Court
challenging the constitutionality of Utilization
Review. The first has been long overdue, since
such states as California, New York, Florida
and others have been beleaguered for many
years; the second points up the lack of foresight
exercised by HEW in promulgating rules, reg-

ulations and controls that were either unwise,
impractical or, at times, impossible.

I consider it unfortunate that many of the
leaders in medicine rushed to support certain
congressmen in proposing government pur-
chase of Health Insurance for the unemployed.
Not only could this possibly include more than
ten million on a federal subsidy, but is just
about as pure a form of socialized medicine as
we have seen in this country. Note that at least
two committees have already sought jurisdic-
tion — the Senate Labor and Public Welfare
Committee and the House Commerce Commit-
tee. It could include not only those who were
jobless solely from adverse national economic
trends, but also those who were jobless from
inefficiency and lack of intent. The care of
worthy persons should be on a local basis,
managed by the state, determined by need; the
physicians would have met this responsibility,
as they did in years past. This would have been
an opportunity once again for the profession to
demonstrate its total public involvement,
without any consideration of remuneration. It
is to their credit that the administration is op-
posed to any plan for jobless coverage since "it
is not feasible or affordable.” The doctors can
and will take care of the medical needs of the
unemployed so long as such conditions exist.
We have always done it — long before
Medicaid and Medicare — and we can and will
do it again! This is a message I sent the com-
mittee hearing a proposal and the message I
sent to our national legislators prior to the on-
set of their deliberations.

Thank you, my Oklahoma colleagues, for all
that you are doing for the people of this state.
Your dedication to their welfare is a joy to
see.

Journal / April 1975 / Volume 68

107

scientific

Penicillin Allergy

JAMES FREED, MD

Penicillin is the most common cause
of allergy to drugs. This report reviews the
pathogenesis of allergy to penicillin,
the types of reactions and outlines
principles of management for patients
with such reactions.

Administration of penicillin is the most
common cause of drug allergy. Manifestations
of penicillin allergy run the gamut from allergic
reactions to immunological mechanisms and
occur in about five per cent of adults: the inci-
dence in children is much lower. Despite the
risk of allergic reactions, penicillins are the
first choice for treating infections because of
their bactericidal activity and relatively low
toxicity.

The rate of penicillin allergy varies from one
per cent to fifteen per cent; this can be explained
by recognizing that (a) the nature of penicillin
preparation, (b) the number of doses adminis-
tered, (c) the mode of administration, and in
particular, (d) the size of the dose, influence the
frequency of allergic reactions.

Present evidence suggests that severe reac-
tions are most likely to occur in patients with a
history of atopy-asthma, hay fever, or atopic
dermatitis. Partly because of the sometime in-

From the Department of Pediatrics, Children’s Memorial Hospital,
University of Oklahoma Health Sciences Center and Department of In-
stitutions, Social and Rehabilitative Services, Oklahoma City, Oklahoma

108

discriminate and injudicious use of penicillin,
such allergic reactions have become increas-
ingly frequent and severe. While anaphylactic
reactions are rare in children, especially
younger ones, the incidence among adults is
increasing. It is estimated that there are 3,000
anaphylactic reactions annually, of which ten
per cent are fatal. The marked increase in inci-
dence and severity of allergic reactions to
penicillin in adults may be a result of the re-
peated and frequent use of penicillin in child-
hood, when it presumably caused no reaction.
Because penicillin is so widely used and acute
reactions can often be prevented by observing
proper precautions, it is important to know the
characteristics of penicillin allergy.

A person who has reacted adversely to
penicillin on one occasion may tolerate it subse-
quently and vice versa. The discovery that some
persons who have never received penicillin can
display hypersensitivity to small doses showed
that the causes of this supposedly specific form
of allergy are broader than the mere use of the
drug. Many people are exposed to penicillins
and may become slightly sensitized to the mi-
nute quantities found in milk and other dairy
products.

The mechanism most commonly involved in
producing untoward effects of penicillin is
hypersensitization. The immune response to
penicillins involves a large variety of antigenic
determinants and several types of immuno-
globulins, yielding a complex picture which is
difficult to interpret.

Allergic reactions to penicillins occur in four
groups. These reactions and their symptoms are
as follows:

Oklahoma State Medical Association

(a) Immediate Allergic Reactions — occur-
ring 2 to 30 minutes after penicillin ad-
ministration:

Urticaria

Hypotension or shock
Laryngeal edema
Wheezing

(b) Accelerated Urticarial Reactions — oc-
curring 1 to 72 hours after penicillin ad-
ministration:

Urticaria or pruritis
Wheezing or laryngeal edema
Local inflammation

Morbilliform eruptions
Urticarial eruptions
Erythematous eruptions
Recurrent urticaria and arthralgia
Local inflammation

(d) Some relatively unusual late reactions:

Drug fever

Immunohemolytic anemia
Acute renal insufficiency
Thrombocytopenia
Serum sickness

Skin reaction may appear in the absence of
previous known exposure to the drug or
promptly after the administration of the first
dose, especially in individuals who have had
prior allergic reactions to other substances.
Eliminating penicillin usually results in rapid
clearing of the allergic manifestations, but they
may persist for two weeks or longer. In some
cases, the reactions are mild and disappear
while penicillin is still being given. Skin rashes
of all forms have been observed when penicillin
sensitization has occurred, most being urticar-
ial. Fever may be the only evidence of a hyper-
sensitivity reaction to the penicillins and usu-
ally disappears 24-36 hours after discontinuing
therapy.

What is the immunological basis of hypersen-
sitivity?

Antigen — Antibody — ) Allergic Reaction

The first requirement for inducing an im-
mune response is a complete antigen. Studies
have shown that low molecular weight com-
pounds (haptenes) must react irreversibly with
proteins to cause sensitization or elicit an aller-
gic reaction.

Hapten — Protein — ) Antigen

Chemically, the penicillins are intermediate

small peptides in the biosynthesis of proteins
which are unique to fungi and, therefore,
foreign to mammals. In the intact or partially
degraded form, they readily couple with larger
peptide or protein molecules by amide, carbon
or disulfide linkages. In this they become an-
tigenic with a specificity determined by the
penicillin molecule acting as a multivalent hap-
ten. All penicillins have the 6-amino penicil-
lanic acid nucleus, and the haptenic determin-
ants have a structure related to the nucleus.
Hence, all forms of penicillin are, to some ex-
tent, cross-allergenic.

In human penicillin allergy of the humoral
type, at least two different antigens are opera-
tive.

These antigens are as follows:

(a) Major determinant, benzylpenicillin
polylysine, and benzylpenicilloyllysine
groups, and

(b) Minor determinant, mixture of benzyl-
penicillin, benzylpenicilloate, and
alpha-benzylpenicilloyl-amine.

Powerful, proteinaceous antigen with
penicilloyl specificity may be present in com-
mercially certified pure penicillin. This an-
tigen, which can stimulate the production of
immunizing and sensitizing antibodies, can
evoke the characteristic anaphylactic responses
in doses of 1 ug or less in sensitized subjects.

The above finding fits well with the fact that
life-threatening anaphylactic responses are
characteristically observed with the natural
penicillins, G and V, since de-acylation and re-
placement of side chains by re-acylation re-
moves the proteinaceous residue from the
semi-synthetic penicillins. Since alimentary
digestion can also remove this proteinaceous
substance, the lower incidence of anaphylactic
reactions with the use of oral penicillin is also
explained.

The possibilities of eliciting penicilloyl-
specific allergic reactions in penicillin therapy
have not been fully explored. Commercial
penicillins are regularly contaminated by small
quantities of penicilloyl compounds. The extent
of this contamination is an important factor in
whether a penicilloyl-specific allergic reaction
occurs during penicillin therapy.

Antipenicillin antibodies are detectable in
virtually all patients who have received the
drug and in many who have never knowingly
been exposed to it.

Two types of antibodies are found: (a) skin-
sensitizing antibodies, involved in anaphylaxis

Journal / April 1975 / Volume 68

109

Allergy / FREED

and urticaria, which some authors feel are of
the IgE family, and (b) hemagglutinating an-
tibodies, IgE and IgM, which are merely indi-
cators of the immunological response and not
the cause of penicillin allergy.

Synthesis of antibodies to both types of de-
terminants (major and minor) appears to be
linked. Clinical and immunological studies
suggest that immediate allergic reactions are
mediated by skin-sensitizing antibodies, usu-
ally of minor-determinant specificities. Accel-
erated and late urticarial reactions are usually
mediated by major-determinant specific, skin-
sensitizing antibodies.

The hemagglutinating antibodies which can
be demonstrated by the hemagglutin technique
are widespread and can be found as often in
non-allergic as in allergic subjects, although in
the latter the titers may be higher. Their pres-
ence is a natural immunochemical reaction to
penicillin in any form. In fact, they may protect
against allergy by acting as ''blocking an-
tibodies” when penicillin is administered, com-
peting for antigen with the skin-sensitizing,
anti-penicilloyl antibodies. Their presence does
not mean that the same individual will inevita-
bly react adversely to penicillin; he has the
capacity to react, but as often as not fails to do
so. This is probably because the excess of
penicillin or its degradation products in uncon-
jugated form act as univalent inhibitors of the
small amount of penicillin conjugated multi-
valently as hapten with protein or peptide in
the injection material or tissue.

There are, therefore, two universal protective
mechanisms against allergy: (a) blockage of an-
tigen by circulating antibodies and (b) hapten
inhibition. Allergy results when these protec-
tive mechanisms are deranged. How then does
the physician decide what to do in cases of
penicillin allergy?

History — A detailed case history of penicil-
lin administration and allergic reactions should
always be taken. Factors of historical signif-
icance include atopy, history of reactions to
other drugs, frequency of penicillin exposure,
route of penicillin administration, and type of
penicillin preparation. If penicillin allergy is
suspected in a patient, the indication for
penicillin therapy should be re-evaluated. In
many cases, penicillin is not absolutely re-
quired or may be replaced advantageously by
another antibiotic. If penicillin must be used

and the history is of no benefit, then predictive
tests are indicated.

The value of objective predictive tests is
twofold:

(a) to screen out the severe allergic reactor to
penicillin and

(b) to enable the physician to use these valu-
able drugs in patients who, although they
have past histories of penicillin allergy,
could now tolerate penicillin therapy
without allergic reaction.

Two preparations are now being used ex-
perimentally in skin testing for penicillin sen-
sitivity:

(a) PPL (Penicilloyl-polylysine, BPO or BPL)
and

(b) MDM (minor determinate mixture)
which contains a solution of penicillin and
several of its degradation products.

These two tests detect skin-sensitizing an-
tibodies (reagins) of benzylpenicilloyl specific-
ity and minor haptenic determinant specificity.
They were designed to detect mainly the im-
mediate, accelerated, urticarial reactors to
penicillin. The tests are based on the hypothesis
that immediate and accelerated reactions to
penicillin are mediated by reagins which are
present prior to penicillin therapy and which
are detectable by skin tests with both PPL and
MDM. PPL is much safer for testing than
penicillin. Furthermore, it gives a much higher
incidence (35% -75%) of positive intracutaneous
test reactions in patients who have histories of
penicillin reactions but have negative skin tests
to penicillin itself.

Negative skin tests for PPL and MDM virtu-
ally exclude the possibility of an immediate al-
lergic reaction and markedly reduce the prob-
ability of an accelerated urticarial reaction to
penicillin. A positive skin test for PPL or MDM
indicates a very high probability of an im-
mediate or accelerated allergic reaction to
penicillin.

Negative skin tests do not exclude the possi-
bility of a positive Coombs’ test or
granulocytopenic or exanthematous reactions

James E. Freed, MD, graduated from the U ni-
versity of Oklahoma College of Medicine in 1 970.
He served an internship and residency in pediat-
rics at the Children s Memorial Hospital and
served as chief resident pediatrician in 1972-73.
He is currently on active duty with the US Air
Force.

110

Oklahoma State Medical Association

to penicillin as these reactions are not mediated
by reagins. Exanthematous reactions, however,
occur more frequently among patients with
positive skin tests.

One must use the MDM in skin testing be-
cause the MD-specific skin-test-positive pa-
tients appear to be those with the highest risk of
an immediate allergic reaction to penicillin.
This seems to be so because of two reasons:

(a) minor determinant specific reagins may
have unusually high binding affinities
and

(b) concentration of minor determinant
specific blocking antibodies may be low.

Since PPL and MDM are not generally avail-
able, many clinicians use a scratch test with
various dilutions of penicillin. This test can be
started with a drop of penicillin G solution con-
taining 1,000 units/ml followed in 20 minutes
by a scratch test with a solution containing
10,000 units/ml. This can be followed by an in-
tradermal test of 0.01 ml of a solution con-
taining 1,000 units/ml. It is best to test with
equivalent dilutions of the specific penicillin
preparation to be used. Whenever skin tests are
performed, epinephrine and a tourniquet
should be at hand so that systemic reactions can
be controlled without delay. If the skin tests are
negative, therapeutic doses of penicillin can be
administered with reasonable assurance that
immediate, life-threatening reactions will not
occur. Penicillin should not be used for either
testing or therapy in patients with a history of
immediate, allergic reactions because the test
itself could be fatal.

There has been some interest in studies of the
serum of penicillin-allergic individuals, mainly
to detect the presence of specific hemag-
glutinating antibodies. In patients with a nega-
tive skin test, the hemagglutination technique
is of no value in predicting immediate reactions
or accelerated, urticarial reactions to penicillin.
If the skin test is positive, the following can be
deduced:

( + ) skin tests — Low hemagglutination —
good chance of anaphylaxis

( + ) skin tests — High hemagglutination —
little chance for anaphylaxis, but may
have accelerated urticarial reaction.

Even with all this, it must be remembered
that any given dose may inhibit as well as pro-;
voke a response; a single trial dose or a single
negative skin test does not always guarantee
safety.

Journal / April 1975 / Volume 68

Ampicillin is associated with drug rash more
often than other penicillins. Yet, from the
molecular structure underlying all of the
penicillin preparations, and from the existence
of cross-reactivity, it might be expected that
each preparation would tend to produce rash
with approximately equal frequency. Further-
more, most of the excess rash with ampicillin
seems to occur after an interval of at least a
week following exposure; during the first week,
rash occurs about as often as with the other
penicillins. Why is this so? First, early rash
with both ampicillin and other penicillins is
related to antigens present in all the prep-
arations. With ampicillin, late rash in some pa-
tients may be due to sensitization to the same
antigens, but the excess, compared with other
penicillins, could be due to the presence of addi-
tional impurities.

The cephalosporin derivatives are often the
alternative drugs of choice for patients who are
hypersensitive to the penicillins and who need a
parenteral or oral agent effective against bac-
terial infections for which a penicillin is indi-
cated. However, the cephalosporins are them-
selves capable of inducing allergic reactions.
The cephalosporins have a different nucleus
from the penicillins and are usually tolerated,
but there is some evidence that a cross-reaction
immunochemical complex with penicillin must
be operating. Some feel that it may represent
common or very similar contaminants. The ac-
tual picture is still not clear. The use of a
cephalosporin in patients allergic to penicillin
is, therefore, not without risk, and the patient
must be closely observed for evidence of an al-
lergic reaction.

If a penicillin is urgently needed by a patient
with a history of immediate reaction or if the
skin tests are positive and the patient cannot
tolerate any alternative drug, desensitization
might be attempted. Such circumstances are,
however, quite rare. Starting several hours be-
fore desensitization is begun, a parenteral cor-
ticosteroid or antihistamine is administered as
an intravenous infusion which is continued dur-
ing the initial stages of desensitization. The
success of desensitization is not predictable, and
it should be done only on hospitalized patients
under constant supervision by experienced per-
sonnel with equipment for respiratory and cir-
culatory assistance at the bedside.

Because of the risk of severe allergic reac-
tions, penicillin should be used with caution

111

Allergy / FREED

and never for mild, self-limiting infections. Ex-
cept in very severe infections, the drug should
be administered orally to avoid the greater risk
of parenteral administration. A physician ad-
ministering penicillin should always be pre-
pared to deal with severe reactions. When there
is reason to believe that the patient is sensitive

to penicillin, another antimicrobial agent effec-
tive against the organism causing the infection I
should be used if possible. In the rare instances i
in which no other drug is a reliable substitute,
skin tests and desensitization to penicillin may
be indicated. When a cephalosporin drug is used
in place of penicillin, the physician should also
be aware of its sensitizing potential. □

PHYSICIANS’ PHOTO CONTEST

Physicians and spouses interested in photography are invited to enter the Oklahoma
Medical Summit Photo Contest to be held during the April 23rd-26th meeting at the Lincoln
Plaza Forum.

The rules are as follows:

Rule 1. All entrants must be members of at least one of the sponsoring organizations of
Oklahoma Medical Summit (OSMA, OCCS, or OAFP) or the spouse of a member.

Rule 2. Entries may be either black and white or color prints with a minimum size of 5 x 7
inches up to a maximum of 16 x 20 inches. (Sorry, no slides or transparencies.)

Rule 3. Photos may be of any subject matter (portrait, scenic, general interest, scientific,

etc.)

Rule 4. All entries must be in the Oklahoma State Medical Association office no later than
Monday, April 21st, 1975 ... or entries may be brought to the Lincoln Plaza Forum on
Wednesday, April 23rd.

Rule 5. Each entry must be clearly marked so that its ownership may be easily ascertained.
All photos will be returned to their owners after the Oklahoma Medical Summit meeting.

Rule 6. No special mountings or frames are required. However, it would be appreciated if
the photos were at least matted on some form of stiff backing.

Rule 7. Entries are limited to two photos per person.

Prizes will be awarded.

MAIL OR SHIP ENTRIES TO: Oklahoma State Medical Association, Attention, Mr. Ed
Kelsay, 601 N.W. Expressway, Oklahoma City, Oklahoma 73118.

112

Oklahoma State Medical Association

Hill of Mercy: Chimborazo
Military Hospital, 1861-1865

RONALD C. CURNUTT, MEd

Chimborazo Hospital, near Richmond,
Virginia, was the largest military
hospital of the Civil War. During the
four years which it served the Confederate
Army, 77,889 patients were admitted.

Chimborazo Hill rises above the James River
near Richmond, Virginia, much like the origi-
nal Chimborazo in the Andes Mountains of
Ecuador.1 At the top of the steep slope rests a
forty acre plain on which the headquarters of
the Richmond National Battlefield Park is now
located. The tree-lined park commands a mag-
nificent view of the surrounding countryside.
Once the site of the largest military hospital in
the United States, today, Chimborazo is used
for recreation and by tourists in search of
America’s past.

After the Confederate Army’s initial victory
Journal / April 1975 / Volume 68

at First Manassas in July, 1861, the Army,
under General Joseph E. Johnston, settled in
for the first winter encampment of the war.
However, camp life proved to be much deadlier
than the sting of battle. Seventy-five percent of
all Confederate military deaths were attributed
to disease. Southern medical records estimate
approximately 3,600,000 cases of disease and
wounds, with 200,000 fatalities.2 In the spring
of 1862, General Johnston’s army, massed at
Centreville, Virginia, had 9,000 sick and
wounded.3 In April, General George B.
McClellan’s Union forces made the opening
moves of the Peninsular Campaign which was
designed to capture Richmond and end the war.
General Johnston immediately needed to trans-
fer his forces from Centreville to the defense of
Richmond. This move necessitated finding
quarters for his sick and wounded. Johnston
presented the problem to Doctor Samuel P.
Moore, the Surgeon-General of the Confed-
eracy. A total of only 2,500 hospital beds were
available in Richmond. Doctor Moore turned to
Doctor James B. McCaw, the administrator of a
small military hospital on Chimborazo Hill
near Richmond.

Doctor McCaw was Surgeon-In-Charge of the

113

Hospital / CURNUTT

1. Doctor James Brown McCaw. (From a photo-
graph)

hospital which had been established in October,
1861, in several unfinished buildings on Chim-
borazo Hill. McCaw was the fourth member of
his family to practice medicine, beginning with
his great-grandfather in the Revolutionary
War. Bom in Richmond on July 21, 1823, he
received his medical education at the Univer-
sity of the City of New York. Before the war, he
served as editor of the Virginia Medical and
Surgical Journal and as Professor of Chemistry
and Pharmacology at the Medical College of
Virginia. During the war, in addition to serving
at Chimborazo with great distinction^ McCaw
also edited the Confederate States Medical and
Surgical Journal, the only medical journal pub-
lished by the Confederacy.4

Chimborazo Hill, lying to the east of Rich-
mond, is separated from the center of town by
Bloody Run Gulch. In April of 1862, the arrival
of 4,000 patients from Johnston’s army at Cen-
tre ville marked the beginning of Chimborazo as
the major medical center of the Confederacy. Of
the 154 military hospitals in the South, Chim-
borazo was the largest. During the war, 77,889
patients were admitted, and the hospital ad-
ministered 8,400 beds at one time.5 Lincoln
Hospital in Washington, DC, which served
46,000 patients, was the largest Union military

114

1. Chimborazo Hill looking toward the James
River Valley and Richmond.

hospital.6 The Secretary of War designated
Chimborazo as an independent army post with
Doctor McCaw as Commandant and Medical
Director. This exempted Chimborazo from the
order of October 28, 1862, which placed general
hospitals under the authority of local military
commanders. McCaw named the institution
Chimborazo Hospital.

Chimborazo Hill was well suited for the site of
a hospital, since the heights offered excellent
ventilation and natural drainage on three sides.
There was an abundance of good water supplied
by three natural springs and five deep wells.
Chimborazo’s proximity to Richmond was also
an advantage. The only Confederate medical
school in operation, the Medical College of Vir-
ginia, was located in Richmond. McCaw served
on the faculty, and students assisted at Chim-
borazo. The office of the Surgeon-General was
also located in the capital at Richmond. Chim-
borazo benefited from the watchful eye of Doc-
tor Moore.

Doctor Moore introduced the hut, or one-story
pavilion hospital.7 Chimborazo had 130 of these
single story buildings. Each building was 100
feet long and 30 feet wide and housed from 40 to !
60 patients. Ventilation was provided by the i
doors and windows. Beds were arranged in j
single rows along each of the ward sides, allow-
ing from 800 to 1,000 cubic feet of air for each j
patient.8 Doctor Charles Tripler, Medical Di-
rector of the Army of the Potomac, commented i
on the buildings: "They admit of more perfect
ventilation, can be kept in better police, are
more convenient for the sick and wounded and
their attendants, admit of a ready distribution
of patients into proper classes, and are

Oklahoma State Medical Association

2. Map of Richmond. (Original composition)

cheaper.” 9 Chimborazo was divided into five
separate hospitals or divisions, each with thirty
buildings or wards. One of Chimborazo’s assis-
tant surgeons recalled, "The hospital presented
the appearance of a large town, imposing and
attractive, with its alignment of buildings kept
whitened with lime, streets and alleys clean.”10
Officers’ wards were separate from enlisted
men. Some patients were housed in Sibley tents
on the slopes of the hill.

The Richmond tobacco factories, closed by the
war, contributed much to Chimborazo Hospital.
Lumber from tobacco packing boxes was used to
build furnishings, and factory boilers were
utilized in Chimborazo’s soup houses. Even to-
bacco laborers were used to construct the hospi-
tal. Chimborazo had all the facilities of a small
village, including a brewery with a capacity of
400 kegs of beer. Storage vaults for the beer
were built into the eastern slope of the hill. The
hospital had a bakery that supplied 10,000
loaves of bread a day, five soup houses, five ice
houses, and a Russian bathhouse. Soap was

Journal / April 1975 / Volume 68

made with the grease from the soup houses.11
There were five morgues in the hospital area,
and Oakwood cemetery was used when needed.
A guard house was maintained for unruly con-
valescents and attendants. The hospital was
administered from the Richard Laughton
house, the only two-story building on the
grounds. St. John’s Church, where Patrick
Henry made his famous "Give me liberty or give
me death” speech was only a few blocks away.

Tree Hill Farm, owned by Franklin Stearns,
pastured Chimborazo’s 200 cows and 500 goats.
Doctor McCaw considered kid meat "most nu-
tritious and palatable for sick and wounded
men.”12 A canal boat, "The Chimborazo,” sailed
the James River obtaining supplies. Late in the
war, Sheridan’s Raiders captured one of
Chimborazo’s boats with a cargo loss of
$58, 889. 13

The Act of September 27, 1862 assigned the
wounded and ill to hospitals by the states from
which they served. This arrangement enabled
officials to locate the patients more quickly and

115

Hospital / CURNUTT

3. Chimborazo Hospital as it looked during the
war. (From a photograph, National Archives)

easily. They were also housed among people
from the same geographical area with common
manners and customs. This facilitated the dis-
tribution of materials sent by state govern-
ments, associations, and private groups. Chim-
borazo handled patients from Maryland, Vir-
ginia, Tennessee, Kentucky and Missouri. Mrs.
Arthur Hopkins, wife of the Chief Justice of
Alabama, helped establish an Alabama section
at Chimborazo later. During the course of the
war, she contributed $200,000 to the relief of
Confederate sick and wounded.14

Chimborazo, like most Confederate institu-
tions, constantly struggled to keep its personnel
up to strength. Each of the five divisions had a
surgeon-in-charge, and there were fifty assis-
tant surgeons assigned to the wards. When
military doctors were not available, contract
surgeons, who ranked below commissioned of-
ficers and received less pay, were used.15

Phoebe Pember, Chief Matron of Division II,
was skeptical of the quality of many of the
surgeons approved for work. She wrote in her
diary, A Southern Woman’s Story, "Coming to
Richmond he [the applicant] passed the board of
surgeons by a process known only to them-
selves, which often rejected good practitioners,
and gave appointments to apothecary boys.”16
Many of the ^oung surgeons were lax in their
duties and attendance. The problem of alcohol
also caused embarrassment to some of the staff.
One intoxicated surgeon set the wrong leg of a
patient. However, the majority of Chimborazo’s
doctors were dedicated and hard-working, as
the remarkable record of the institution indi-
cates.

The second largest group of hospital person-
nel at Chimborazo was the matrons. There were
forty-five matrons on the staff with Mrs. Minge
as Head Matron.17 The Act of September 1862
authorized two head matrons, and two matrons
for each ward. Preference, in all cases, was to be

116

given females "where their services may best be
used.”18 Mrs. Pember commented on the open-
ing of a position for women: "Now that the field
was open, a few, very few ladies, and a great
many inefficient and uneducated women,
hardly above the laboring classes, applied for
and filled the offices.”19 Feminine entrance into
the male domain did not go unnoticed. The new
matrons were called the "petticoat govern-
ment.” On Mrs. Pember’s first day, she over-
heard a member of the staff comment, "one of
them has come.”20 Mrs. Pember described her
duties: "I have entire charge of my department,
seeing that everything is cleanly, orderly, and
all prescriptions of physicians given in proper
time, food properly prepared and so on.”21

The Act of August 21, 1861 authorized south-
ern hospitals to employ nurses, cooks, and other
needed personnel. These staff members were
under military control, and their pay was less
than that allowed enlisted men. Stewards were
responsible for the cleanliness of the wards,
kitchens, and patients, and were also custo-
dians of the hospital store. Convalescent pa-
tients were expected to help when needed.
Surgeon-General Moore wrote his medical di-
rectors: "Soldiers who have lost their left hand
or arm, and otherwise healthy, but who are
incompetent to perform clinical duty, can in the
use of a pistol, act as efficient guards for hospi-
tals and purveying depots.” 22 Convalescents
were used for guarding, gardening, and even
nursing. Mrs. Pember felt, "This arrangement
bore very hard upon all interested, and harder
upon the sick, as it entailed constant supervi-
sion and endless teaching.”23 John Herbert
Claiborn directed Chimborazo’s Commissary.
The Quartermaster was Colonel A. S. Buford.
There were also two apothecaries, one clerk,
and a chaplain.24

Chimborazo, an official army post, had a de-
tail of thirty soldiers commanded by Captain
Thomas E. Ferrell, whose duty was to maintain
order. By early 1863, Chimborazo’s garrison in-

Ronald C. Curnutt has a BA and an M Ed
summa cum laude from Central State Univer-
sity. He was listed in Outstanding Young Men of
America in 1973. Mr. Curnutt is now teaching
history at Arizona Western College and Parker
High School, Parker, Arizona. This paper was
originally written during a course in the History
of Biomedical Sciences at the University of
Oklahoma Health Sciences Center.

Oklahoma State Medical Association

creased to 164 troopers on active duty. By an
order of July 8, 1863, four days after the defeat
at Gettysburg, all fit men were ordered to the
front. Replacements for the hospital garrison
were made up of convalescing soldiers. The
South’s "peculiar institution” also played a role
at Chimborazo. Doctor McCaw believed that it
would have been impossible to continue the
hospital without aid of the 256 slaves assigned
there. Paper work was another burden handled
by the administration of Chimborazo Hospital.
An order of Doctor McCaw’s, dated January 16,
1863, directed that all surgeons-in-charge hand
in on the first of each month the following:

1. An accurate list of all the servants stating
the names of owners and rate of hire.

2. A list of medical officers noting all changes
during the past month and giving the
ranks and date of appointment of those
who came in during the month.

3. A monthly report of the sick and wounded
accompanied by a list of the patients vacci-
nated and a report of the surgical cases.

4. All other reports required by the regula-
tions.

All requisitions as far as possible must
be made according to regulations stating
length of time and number of patients
meant for. They must also state the quan-
tity of each article on hand. The patients,
nurses, and attendants must be carefully
counted on the 10th, 20th and 31st of each
month and the morning report corrected
thereby.25

McCaw’s own paperwork was not immune to
criticism. Surgeon-General Moore wrote: "All
accounts current sent from your hospital are
full of defects, and made out in a manner which
does not meet the approbation of this office.” On
one occasion, authorities complained that his
morning reports were carelessly and inaccu-
rately kept.26

Chimborazo, like all institutions, lived by its
schedule. Breakfast was served at 7:00 am dur-
ing the summer and at 8:00 am during the
winter. After breakfast, surgeon’s rounds were
made. The surgeon-in-chief received reports
from the division surgeons once a day. The divi-
sion surgeons made ward rounds once a day,
while the assistant surgeons made rounds twice
a day. During the rounds, the assistant
surgeons filled out the diet lists at the foot of
each patient’s bed. These printed forms in-
cluded the patient’s name, bed number, type of
diet, and quantity of whiskey allowed. Dinner

was served at 2:00 pm and supper at 6:00 pm.
All transportation from the hospital was dis-
continued at 8:00 pm.

Near the end of the war, the staff acquired
another duty. Three of the oldest surgeons were
chosen to serve on a board which granted pa-
tient furloughs. This was a thankless task
which required strict adherence to the rules to
prevent abuses.

The Act of September 27, 1862 also set up
financing for southern hospitals. Rations were
fixed at a commutation of $1.00 per man. This
money was placed in a hospital fund to purchase
supplemental rations which were unavailable
in government stores. The amount was fre-
quently raised as inflation diluted southern
currency.27 The finances at Chimborazo were
always in good order. McCaw reported, "We
never overdrew fifty dollars from the Confeder-
ate States Government, but relied solely upon
the money received from commutation of our
rations.” At the close of the war the Confederate
Government owed Chimborazo a sum of nearly
$300, 000.28

All commodities, including medical supplies,
became scarce in the South as the blockade and
war continued. The Union Government de-
clared all medicines and surgical instruments
contraband. Those supplies which were slipped
through the blockade were expensive and hard
to find. No source was overlooked in the search
for medical necessities. Medical supplies were
captured from the Union Army, supplied by do-
nations of private individuals, and illegally
traded for cotton with northern traders. The
South also maintained a number of phar-
maceutical laboratories during the war.
Surgeon-General Moore, who did extensive
work on native remedies, requested that Doctor
McCaw test and investigate these at
Chimborazo.29

Almost 78,000 patients were admitted to
Chimborazo, but only 17,000 of these were bat-
tle casualties. Approximately 7,000 of those
treated for wounds died. Chimborazo’s overall
mortality rate was a little over nine percent.30
Surgeon S. E. Habershame reported that the
most serious diseases treated at Chimborazo
included adynamic fevers, sloughing pha-
gedema, phosedena, gangrenosa, pyemia,
erysipelas and neuralgic afflictions following
continued fever.31 Chimborazo medical records
showed the following statistics on disease:

Pneumonia and pleurisy, 1,568 cases, 583
deaths.

Journal / April 1975 / Volume 68

117

Hospital / CURNUTT

2. Chimborazo Park, the hospital site today.

Debility and anemia, 5,780 cases, 117
deaths.

Scurvy, 119 cases, 8 deaths.

Rheumatism, 1,984 cases, 90 deaths.
Typhoid, 1,388 cases, 661 deaths.
Erysipelas, 236 cases, 22 deaths.
Tuberculosis, Catarrh, Bronchitis, 189
cases, 52 deaths.

Diarrhea and dysentery 10,503 cases, no
deaths.32

Many of the surgical operations performed at
Chimborazo were secondary amputations fol-
lowing initial surgery done at the battlefield aid
stations. Mrs. Pember commented:

Poor food and great exposure had thinned
the blood and broken down the system so
entirely that secondary amputations per-
formed in the hospital almost invariably
resulted in death, after the second year of
the war . . . The only cases under my ob-
servation that survived were two Irish-
men, and it was really so difficult to kill an
Irishman that there was little cause for
boasting on the part of the officiating
surgeons.3^

Military hospital life during the Civil War
was not very different from that of today. Food
was especially significant to the patients. A pe-
tition complaining about the quality of the hos-
pital diet, signed by 360 patients, was read on
the floor of the Confederate Congress, in Sep-
tember of 1862. The prescribed meals in Con-
federate hospitals were full, half, or low diets. A
full diet consisted of beef, bread, and vegetables;
a half diet of soup, toast, and other light foods; a
low diet was rice and milk. The attending
surgeon determined the diet plan for each pa-

118

tient. It was not always possible to provide the
type of food requested by the men. Mrs. Pember
noted, "The habit so common among physicians
when dealing with the uneducated people of
insisting upon particular kinds of diet, irrespec-
tive of the patient’s tastes, was a peculiar griev-
ance that no complaint during four years ever
remedied.”34

Shortages of food and supplies became major
problems in the South as the war continued.
Many humanitarian civilian groups contrib-
uted supplies to supplement the hospital ra-
tions. The women of Richmond made the
Christmas of 1863 a feast day in Phoebe
Pember’s division. She stated:

We made twenty-four gallons of eggnog
inviting all in the whole division to come
and drink and gave to each a good sized
cake. At two o’clock having roasted a
dozen turkeys and seven gallons of oysters
we shared them out and hoped that each
man got his share.35

A most highly prized item in the matron’s
store room was the supply of spiritous liquors.
Each division was allotted one barrel a month
for medicinal purposes. The ward surgeons
would prescribe each patient’s daily ration on
his bed card. The matron was in charge of hold-
ing and dispensing the spirits. This duty caused
many of the matrons great anxiety since
everyone wanted a share of the scarce liquor
supply. The doctors and hospital stewards did
little to help, and sometimes hindered, the ma-
trons with this worrisome chore.

The soldiers of the Confederacy found hospi-
tal life filled with monotony. Hospital desertion
rates were high. The Department of Virginia
reported 5,895 desertions between September of
1862 and August of 1864. 36 Discipline was al-
ways a problem, with theft, drunkenness, and
gambling especially prevalent. The boredom
was relieved by revival meetings, books from
the library, and handicrafts. The men made
toys and carved pipes. One patient in Division II
was able to get as much as $150 for his carved
pipes made from ivy roots. Playing cards were
always in great demand and short supply. The
hospital saw many fads come and go. At one
time, every patient desired a pair of crimson
canvas shoes dyed with red juices. A button
mania swept the wards with each patient trying
to outdo the other. There was even a hat band
"fever.” The patients put gilt and tinsel bands
around their hats and wore them in bed.

Mail and visitations were sources of great

Oklahoma State Medical Association

comfort to the patients at Chimborazo. Mrs.
Pember wrote that "Homesickness which
wrings the heart and impoverished the blood
killed many a brave soldier.”37 She wrote letters
for the patients, but required them in return to
perform some task of personal hygiene. Mail
call was such an important event in hospital
life, that the patients sent Doctor McCaw a peti-
tion asking for removal of the Chimborazo
postmaster because he mispronounced the
names on more than half the letters, took too
long to make mail call, and made remarks about
the writing on the letters. Visitations were hard
to control since few rules seemed to regulate
them. A Mrs. Daniels had a baby while visiting
her husband. Another large family just moved
in for six days and refused to leave. Such unwel-
come guests were called "hospital rats.”

Chimborazo passed its peak patient load by
1864. The morning reports for January, 1864
listed only 578 sick and wounded present. Doc-
tor McCaw was ordered to transfer one of the
divisions and let all nonessential personnel go.
As the war’s end neared, Chimborazo convales-
cents were expected to do their share of military
duty. On Sunday, April 2, 1865, General Dick
Ewell sent word to Captain Wood of the
hospital’s military garrison that Chimborazo’s
personnel were needed for the defense of Rich-
mond. This last military service mobilized
1,200 staff members and convalescents.38 The
day after Richmond was evacuated by the Con-
federates, the Union Army, led by General God-
frey Wetzel, arrived at the hospital. Doctor
McCaw was there to meet the new masters of
Chimborazo Hill. Wetzel offered to place
McCaw in the service of the United States so
that he would have official authority to contin-
ue his duties. McCaw refused, however, stating
that General Lee had not yet surrendered and
that such action would be inappropriate.39

The Federal Army took over the administra-
tion of Chimborazo, but the matrons were al-
lowed to continue caring for Confederate pa-
tients. Rations remained scarce until the James
River was cleared of obstructions. After making
her last rounds of Division II, Mrs. Pember
noted cynically:

Then I walked through my wards and
found them comparatively empty. Every
man who could crawl had tried to escape a
northern prison. Beds in which paralyzed,
rheumatic, and helpless patients had laid
for months were empty. The miracles of
the New Testament had been re-enacted.

The lame, the halt, and the blind had been
cured.40

A remarkable feat was accomplished at
Chimborazo Hospital during the war despite
the enormity of the task, the limitations of med-
ical knowledge, the scarcity of supplies, and the
restrictions on personnel. Chimborazo’s place in
history as America’s largest military medical
center was well-earned. □

ACKNOWLEDGEMENTS

Editorial help was given by Virginia R. Allen,
PhD, Instructor of History of Medicine, University of
Oklahoma Health Sciences Center. History of Medi-
cine work is partly supported by grants from the
National Library of Medicine, National Institutes of
Health (Grant LM-01396) and the Oklahoma Medi-
cal Research Foundation.

FOOTNOTES

1. Interview, Park Ranger, Richmond National Battlefield Park, August 12,
1973.

2. H. H. Cunningham, Doctors in Gray: The Confederate Medical Service
(Gloucester, Mass: Peter Smith, 1970), p. 3.

3. Frank S. Johns and Ann Page Johns, "Chimborazo Hospital and J. B.
McCaw, Surgeon-in-Chief.” The Virginia Magazine of History and Biography,
LXII (1954), p. 190.

4. Fielding Garrison, "Dr. James Brown McCaw.” Old Dominion Journal of
Medicine and Surgery, V (August 1906), p. 1.

5. Cunningham, p. 4.

6. Ibid., pp. 29-30.

7. Johns, p. 193.

8. Cunningham, p. 50.

9. Johns, p. 193.

10. John R. Gildersleeve, "History of Chimborazo Hospital, Richmond, Vir-
ginia and its Medical Officers during 1861-1865.” The Virginia Medical
Monthly, IX (1904), p. 150.

11. Johns, p. 194.

12. Cunningham, p. 65.

13. Bell Irvin Wiley, Embattled Confederates (New York: Harper and Row,
1964), p. 168.

14. Phoebe Yates Pember, A Southern Woman’s Story, edited by Bell Irwin
Wiley (Jackson, Tenn: McCowat-Merier, 1959), p. 27.

15. Ibid., pp. 76-77.

16. Gildersleeve, p. 151.

17. Cunningham, p. 73.

18. Pember, p. 24.

19. Ibid., d. 26.

20. Ibid., p. 151.

21. Cunningham, p. 78.

22. Pember, p. 27.

23. Gildersleeve, p. 151.

24. Johns, p. 196.

25. Cunningham, p. 258.

26. Ibid., p. 80.

27. Gildersleeve, p. 27.

28. Cunningham, pp. 134-150.

29. Johns, pp. 190-198.

30. Edgar E. Hume, "Chimborazo Hospital, Confederate States Army,
America’s Largest Military Hospital.” The Virginia Medical Monthly, LXI
(1934), p. 193.

31. Cunningham, pp. 185-238.

32. Pember, p. 108.

33. Ibid., p. 35.

34. Ibid., p. 178.

35. Cunningham, p. 90.

36. Pember, p. 13.

37. Burke Davis, To Appomattox: Nine Days, 1865 (New York: Popular Lib-
rary, 1960), p. 137.

38. John R. Gildersleeve, "Chimborazo Hospital During 1861-1865.” The
Confederate Veteran, XII (1904), p. 58.8.

39. Pember, p. 137.

c/o History of Medicine

P.O. Box 26901, Oklahoma City, Oklahoma 73190

ILLUSTRATIONS
Drawings by Miss Debbie Krieger

Photographs by Author

Journal / April 1975 / Volume 68

119

Announcing

ANNUAL SPRING
SYMPOSIA

GYNECOLOGY AND OBSTETRICS

THE OVARY

MAY 29TH AND 30TH, 1975

THE UNIVERSITY OF OKLAHOMA
HEALTH SCIENCES CENTER
OKLAHOMA CITY, OKLAHOMA

The Annual Spring Symposia this year features an
outstanding guest faculty for a two-day meeting de-
voted to a comprehensive discussion of the Ovary.
Discussions will be concerned with the physiology,
pathology and therapy of the ovary and ovarian dis-
orders. As in previous symposia, there will be ample
opportunity for interaction between the registrant
and the faculty.

GUEST FACULTY

RICHARD C. BORONOW, Professor of Obstetrics &
Gynecology, University of Mississippi School of
Medicine, Jackson, Mississippi

RICHARD j. BLANDAU, Professor of Biological
Structure, University of Washington School of
Medicine, Seattle, Washington

A. BRIAN LITTLE, Professor of Obstetrics &
Gynecology, Department of Reproductive Biology,
Case-Western Reserve University School of
Medicine, Cleveland, Ohio

L. RUSSELL MALINAK, Associate Professor of Ob-
stetrics & Gynecology, Baylor College of Medicine,
Houston, Texas

120

Pro-Banth

brand of

propantheline bro

Indications: Pro-BanthTne is effective a
adjunctive therapy in the treatment of f
ulcer. Dosage must be adjusted to the
individual.

Contraindications: Glaucoma, obstruct
disease of the gastrointestinal tract,
obstructive uropathy, intestinal atony, t
megacolon, hiatal hernia associated wi
reflux esophagitis, or unstable cardiovi
adjustment in acute hemorrhage.
Warnings: Patients with severe cardiac
disease should be given this medicatio
with caution. Fever and possibly heat s
may occur due to anhidrosis.
Overdosage may cause a curare-like a*
with loss of voluntary muscle control.
For such patients prompt and continuir
artificial respiration should be applied
the drug effect has been exhausted.
Diarrhea in an ileostomy patient may in
obstruction, and this possibility should
sidered before administering Pro-Barit
Precautions: Since varying degrees of
hesitancy may be evidenced by elderly
with prostatic hypertrophy, such patier
should be advised to micturate at the ti
of taking the medication.

Overdosage should be avoided in patic
severely ill with ulcerative colitis.
Adverse Reactions: Varying degrees o
drying of salivary secretions may occu
well as mydriasis and blurred vision. Ir
addition the following adverse reactior
been reported: nervousness, drowsine
dizziness, insomnia, headache, loss of
sense of taste, nausea, vomiting, consl
impotence and allergic dermatitis.
Dosage and Administration: The
recommended daily dosage for adult o
therapy is one 15-mg. tablet with meal;
two at bedtime. Subsequent adjustmer
the patient’s requirements and toleran
must be made.

How Supplied: Pro-BanthTne is supplie
tablets of 15 and 7.5 mg., as prolongec
acting tablets of 30 mg. and, for paren
use, as serum-type vials of 30 mg.

Searle & Co.

San Juan, Puerto Rico 00936

Address medical inquiries to: G. D. Searle & C
Medical Department, Box 5110, Chicago, III. 6

SEARLE

Oklahoma State Medical

Association

Measles — Preventable!

One out of every six cases of measles has
complications. One case in every thousand will
die!

In recent weeks several outbreaks of measles
have occurred in Oklahoma. In each instance
the outbreak was controlled by rapid con-
firmation of diagnosis and "containment im-
munization.”

Though measles immunization levels are
quite satisfactory in many areas of the state,
some communities still have levels sufficiently
low to support local outbreaks. Sporadic cases
can occur in any part of Oklahoma.

Measles should therefore be considered in all
cases of rash illness. Unsatisfactory immuniza-
tion can result in the appearance of atypical
cases so that serological documentation of diag-
nosis is important.

The further attenuated vaccines have effi-
cacy rates of approximately 95%. Immunization
rates in school-age children are high enough in
most areas of Oklahoma so that most cases are

News From
The Oklahoma State
Department of
Health

occurring in persons immunized with earlier
vaccines (Edmonston B Strain), and in a small
percentage (less than five percent) of children
immunized with the further attenuated vac-
cines.

Eradication of measles in Oklahoma is possi-
ble during 1975. The number of outbreaks oc-
curring and the numbers of cases involved
make "outbreak containment” an attainable
goal. No doubt measles cases will be imported
from other states from time to time, however
outbreaks can be prevented if diagnosis is accu-
rate and reporting is prompt. Suspect measles
cases should be reported to your local health
department by telephone (collect). If your
county has no health department, call the
number at the bottom of this page. □

COMMUNICABLE DISEASES IN OKLAHOMA FOR FEBRUARY, 1975

DISEASE

February

1975

February

1974

January

1975

Total To Date
1975 1974

Amebiasis

Brucellosis

—

Chickenpox

185

125

389

135

Encephalitis, Infectious

—

Gonorrhea (Use Form ODH-228)
Hepatitis, A, B, Unspecified

921

734

998

1919

1612

128

100

173

208

< Leptospirosis

—

Malaria

—

Meningococcal Infections

Meningitis, Aseptic

Mumps

Rabies in Animals

Rheumatic Fever

—

1 Rocky Mountain Spotted Fever

—

Rubella

Rubella, Congenital Syndrome

—

Rubeola

Salmonellosis

Shigellosis

103

122

Syphilis, Infectious
(Use Form ODH-228)

Tetanus

—

Tuberculosis, New Active

Tularemia

—

Typhoid Fever

—

Whooping Cough

—

For Consultation Call: (405) 271-4060

Journal / April 1975 / Volume 68

125

HEALTH CARE MANAGEMENT

MASSES OF PAPERWORK AND SLOW RECEIVABLES

. these two enemies are overwhelming todays Medical
Office! How to deal with these two is the “number one
business problem” for many doctors.

HCM’s system is simple, easy to learn, requires no
special equipment, is flexible, and can follow along the
lines of your present business office procedures.

For further information, contact:
Gene Highfill

Academy Computing Corporation
3535 NW 58th — Suite 102
Oklahoma City, Oklahoma 73112
405/947-7746

SPONSORED BYTHE OSMA

Washington National Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE
DISABILITY INCOME INSURANCE

Contact Association Counselors:

Jim Thaxton, Bill Howard or Rodman A. Frates

Administrators

720 NW 50th

PO Box 1 8593 405 842-3735 Oklahoma City 73118

126

Oklahoma State Medical Association

JOURNAL

Oklahoma Medical Summit ’75

(OAFP — OCCS — OSMA)

Oklahoma Medical Summit ’75 is the com-
bined annual meeting of the Oklahoma Acad-
emy of Family Physicians, Oklahoma City Clin-
ical Society and the Oklahoma State Medical
Association. It is scheduled for April 23rd-26th
in the Lincoln Plaza Hotel’s Forum.

Oklahoma Medical Summit is the state’s
largest medical continuing education meeting.
Over 70 hours of continuing education will be
offered in addition to numerous courses of in-
terest to allied health personnel. The American
Academy of Family Physicians is allowing 20
hours of prescribed credit for the meeting.

Oklahoma Medical Summit ’75 will feature
numerous social functions beginning on Wed-
nesday evening, April 23rd, with the Early Bird

Party in the Lincoln Plaza Playhouse. Thurs-
day evening, early, there will be a double-
header: a Keg and Oyster Party and a Wine and
Cheese Tasting Party. The social highlight of
the year will be the President’s Dinner-Dance
on Friday evening, April 25th.

Oklahoma Medical Summit ’75 planning has
taken literally thousands of man-hours on the
part of its various planning committees. Their
purpose was to make this combination of the
69th Annual OSMA Meeting, 45th Annual
Clinical Society Meeting, and 27th Annual Sci-
entific Assembly of the Academy of Family
Physicians one of the finest programs
available. □

INDEX

Oklahoma Medical Summit

Officers and Trustees . . . .

129

Summit Officials

......... .130

Digest of Events

132

Technical Exhibitors

135

Program

137

Summit ’75 Entertainment

......... .142

Summit Superstar Luncheon Speakers

. . 143

Agenda, House of Delegates

. . . 144

Photo Contest and Photography Seminar . .

144

Delegates and Alternates

......... .145

Woman’s Auxiliary

128

Oklahoma State Medical Association

Jack L. Richardson, MD
Tulsa
President

Arnold G. Nelson, MD
Midwest City
President-Elect

Haven W. Mankin, MD
Oklahoma City
Secretary-Treasurer

Roger J. Reid, MD
Ardmore
Vice-President

S. N. Stone, MD
Oklahoma City
Speaker, House of
Delegates

Jack D. Fetzer, MD
Woodward

Vice-Speaker, House

of Delegates

OFFICERS

JACK L. RICHARDSON, MD, Tulsa . . . .President
ARNOLD G. NELSON, MD,

Midwest City President-Elect

ROGER J. REID, MD, Ardmore . . . .Vice-President
HAVEN W. MANKIN, MD,

Oklahoma City Secretary- Treasurer

john a. McIntyre, md,

Enid, Chairman, Board of Trustees

District I: Craig, Delaware, Mayes, Nowata,
Ottawa, Rogers, Washington

Trustee (1976) Jess D. Green, Jr., MD, Bartlesville

Alternate (1976) Edward W. Allensworth, MD, . . . .Vinita

STANLEY R. McCAMPBELL, MD,

Oklahoma City Past-President

S. N. STONE, MD,

Oklahoma City .... Speaker, House of Delegates
JACK D. FETZER, MD,

Woodward Vice-Speaker, House of Delgates

District V: Beckham, Blaine, Canadian,
Custer, Roger Mills

Trustee (1976) Ross Deputy, MD, Clinton

Alternate (1976) F. W. Hollingsworth, MD, El Reno

TRUSTEES

District II: Kay, Noble, Osage, Pawnee, Payne

Trustee (1976) Thomas C. Glasscock, MD Ponca City

Alternate (1976) Richard F. Harper, MD, Pawhuska

District III: Garfield, Grant, Kingfisher, Logan

Trustee (1976) John A. McIntyre, MD, Enid

Alternate (1976) Ray V. McIntyre, MD, Kingfisher

District IV: Alfalfa, Beaver, Cimarron, Dewey, Ellis
Harps*, Major, Texas, Woods, Woodward

Trustee (1976) John X. Blender, MD, Cherokee

Alternate (1976) Richard H. Burgtorf, MD, Shattuck

District VI: Oklahoma

Trustee (1977) James B. Eskridge, III, MD, Oklahoma City
Alternate (1977) Perry Lambird, MD, . . . .Oklahoma City
Trustee (1977) John A. Blaschke,

MD, Oklahoma City

Alternate (1977) Kent Braden, MD, Oklahoma City

District VII: Cleveland, Creek, Lincoln,
Okfuskee, Pottawatomie, McClain

Trustee (1977) Casey Truett, MD, Norman

Alternate (1977) Clinton Gallaher, MD, Shawnee

District VIII: Tulsa

Trustee (1977) Paul A. Bischoff, MD, Tulsa

Alternate (1977) Harold W. Calhoon, MD, Tulsa

Journal / April 1975 / Volume 68

129

Trustee (1977)William M. Benzing, Jr., MD, Tulsa

Alternate (1977) Myra A. Peters, MD, Tulsa

District IX: Adair, Cherokee, McIntosh,
Muskogee, Okmulgee, Sequoyah, Wagoner

Trustee (1977) Thomas S. GafTord, Jr., MD, . . . .Muskogee
Alternate (1977) Burdge F. Green, MD, Stilwell

District X: Haskell, Hughes, Latimer,
LeFlore, Pittsburg, Seminole

Trustee (1976) Jack W. Parrish, MD, Seminole

Alternate (1976) Delta W. Bridges, Jr., MD, . . .McAlester

District XI: Atoka, Bryan, Choctaw, Coal,
McCurtain, Pushmataha

Trustee (1975) Thomas E. Rhea, MD, Idabel

Alternate (1975) Bill E. Woodruff, MD, Hugo

District XII: Carter, Garvin, Johnston, Love,
Marshall, Murray, Pontotoc

Trustee (1975) Frank W. Clark, MD, Ardmore

Alternate (1975) Clarence P. Taylor, MD, Ada

District XIII: Caddo, Comanche, Cotton,
Tillman, Grady, Jefferson, Stephens

Trustee (1975) Paul N. Vann, MD, Lawton

Alternate (1975) A. Craig Roberson, MD, Anadarko

District XIV: Greer, Harmon, Jackson,

Kiowa, Washita

Trustee (1975) Fred W. Sellers, MD, Mangum

Alternate (1975) Lowell N. Templer, MD, Altus

SUMMIT OFFICIALS

Jack L. Richardson, MD
President
Oklahoma State
Medical Association

Arnold G. Nelson, MD
President

Oklahoma City Clinical
Society

Leonard R. Diehl, MD
President

Oklahoma Academy

Family Physicians

GENERAL CHAIRMAN

Marion C. Wagnon, MD

Steering Committee

Harold W. Calhoon, MD, (OSMA)
Casey Truett, MD, (OSMA)

Samuel A. Wheeler, MD, (OSMA)
James D. Funnell, MD, (OCCS)
Arnold G. Nelson, MD, (OCCS)

Joe M. Parker, MD, (OCCS)

William G. Bernhardt, MD, (OAFP)
Howard P. Mauldin, MD, (OAFP)
Joseph Salamy, MD, (OAFP)

Scientific Program

James D. Funnell, MD, Chairman

Physical Properties

Howard P. Mauldin, MD, Chairman

Registration

Kenneth W. Whittington, MD, Chairman

Social Functions

Donald R. Resler, MD, Chairman

Sports Activities

Lee A. Ison, MD, Chairman

Publicity and Medical Liaison

Casey Truett, MD, Chairman

Advisory Committee

Kent Braden, MD, Chairman of ’74 Summit
Armond H. Start, MD, Chairman of ’73 meeting

Exhibits Ladies Representative

Samuel A. Wheeler, MD, Chairman Mrs. Karl K. Boatman

130

Oklahoma State Medical Association

DODD

Oklahoma State Medical Association

BALKAN ADVENTURE

Bucharest - Istanbul -Dubrovnik

9£i

— i

Oklahoma City, July 19, 1975
JOIN US FOR A VACATION
SPECTACULAR

PRICE $1128

A CAREFREE, DO-AS-YOU- PLEASE

TWO WEEK HOLIDAY WITH

EXCLUSIVE FEATURES INCLUDING:

• Direct flights via World Airways
chartered jet

• Deluxe hotels

• American breakfasts; gourmet
dinners at a selection of the finest
restaurants

» Generous 70 pounds luggage

• Optional sightseeing tours

• Expedited Customs formalities

• Tips and Transfers

SEND TO OKLAHOMA STATE MEDICAL ASSOCIATION
601 N.W. Expressway
Oklahoma City, Oklahoma 73118

Enclosed is my check for $ ($100 per person) as deposit.

Names

Address

y® City

State

Zip

Another Non-Regimented INTRAV Deluxe Adventure

DIGEST OF EVENTS

REGISTRATION

The registration area for Oklahoma Medical
Summit ’75 will be located in the lobby of the
Lincoln Plaza Forum Building, 4345 Lincoln
Boulevard, Oklahoma City. It will be open
from 7:30 am until 5:00 pm Thursday through
Saturday, April 24th-26th.

Admission to all scientific sections, exhibits
and business meetings is by badge only, avail-
able in the registration area.

HEADQUARTERS

The Lincoln Plaza Hotel is the headquarters
for Oklahoma Medical Summit ’75. It is located
at 4345 Lincoln Boulevard. All scientific meet-
ings will be held in the Lincoln Plaza Forum
Building, to the immediate south of the hotel
building.

EXHIBITS

Nearly 100 exhibits will be located in the
exhibit hall of the Lincoln Plaza Forum Build-
ing. The exhibit hall will be open from 8:00 am
until 5:00 pm each day during the meeting.

MESSAGE CENTER

A message center will be maintained in the
registration area throughout Oklahoma Medi-
cal Summit ’75. The center will be available to
receive messages and forward them to physi-
cians attending the meeting.

PUBLIC SPEAKING SEMINAR

A Public Speakers Training Program will be
conducted on Thursday and Friday, April
24th-25th, by the Smith, Kline and French
Speakers Training Team. Attendance at the
seminar is limited to 40 persons and advanced
registration is necessary. Participants in the
program will learn the principles of effective
speech composition and delivery, manuscript
speaking, extemporaneous speaking, and the
use of visual aids. The seminar requires two
full-days, from 8:30 am until 5:00 pm and fol-
lows a workshop format.

132

PHOTOGRAPHY SEMINAR

Amateur photography is rapidly becoming
one of the most popular hobbies among physi-
cians. A photography seminar for amateurs
has been arranged for Saturday afternoon,
April 26th. Presentations will be given by
Raymond Riggs, an international salon ex-
hibitor in amateur photography, and David
Fitzgerald, a commercial photographer from
Oklahoma City. The seminar will cover such
subjects as camera selection, lens selection,
film, handling techniques, composition, light-
ing and a few "tricks of the trade.”

Following their formal presentations, the
two photographers will be available for a ques-
tion and answer session.

OSMA BOARD OF TRUSTEES

The OSMA Board of Trustees will conduct its
annual business meeting Wednesday morning,
April 23rd, starting at 9:00 am in the Lincoln
Plaza Rotunda Room.

OAFP BOARD OF DIRECTORS

The Board of Directors of the Oklahoma
Academy of Family Physicians will conduct a
business meeting on Wednesday afternoon,
April 23rd, starting at 1:00 pm in the Lincoln
Plaza Forum Rotunda Room.

OSMA HOUSE OF DELEGATES

The OSMA House of Delegates will conduct
two business sessions during Oklahoma Medi-
cal Summit ’75. The opening session will be
held Wednesday afternoon, April 23rd in the
Lincoln Plaza Hotel’s Lincoln Room. The meet-
ing will start at 2:30 pm.

Reference Committees will meet starting at
8:00 am the following morning, Thursday,
April 24th. Reference Committee meetings are
open to all members of the association and will
be held in the Lincoln Plaza Forum Building.

The closing session of the House of Delegates
is scheduled for 9:00 am Friday morning, April

Oklahoma State Medical Association

25th, in the Lincoln Plaza Hotel’s Lincoln
Room.

All items of business introduced during the
opening session on Wednesday will be referred
to one of the three Reference Committees for
hearing on Thursday morning. Open hearings
are held on all reports and resolutions to be
considered by the House of Delegates.

Following the open Reference Committee
hearings, the Reference Committees will pre-
pare reports containing recommendations for
presentation to the House of Delegates at its
closing session on Friday morning. The elec-
tion of officers will also be held during the clos-
ing session.

SCIENTIFIC PROGRAM

Over 70 hours of continuing medical educa-
tion will be available during Oklahoma Medi-
cal Summit. The American Academy of Family
Physicians has stated that it will allow its
members a maximum of 20 prescribed hours.

Each of the three days will feature a number
of different scientific sections available for
physician-attendants.

WET CLINICS

There will be four wet clinics offered twice
each during Oklahoma Medical Summit. These
will be scattered throughout the first two days,
Thursday and Friday, and will be on dermatol-
ogy, ENT, emergency medicine and cosmetic
surgery.

SUPERSTAR SPEAKERS

Four nationally prominent speakers and the
Governor of Oklahoma will appear during
Oklahoma Medical Summit ’75. The superstar
speakers include Joe T. Nelson, MD, American
Medical Association Trustee; Herbert Hold-
en, MD, President of the American Academy
of Family Physicians; Phillip Thorek, MD,
one of the nation’s most sought after physi-
cian speakers; and, Henry Simmons, MD,
Director of HEW’s Office of Professional Stand-
ards Review.

In addition the new provost of the Oklahoma
Health Sciences Center, William Thurman,
MD, will appear.

Governor David L. Boren will be a featured
speaker on Saturday, April 26th. □

Offering complete private Psy-
chiatric Services using the
Therapeutic Community ap-
proach in an open setting.

Fully Accrediated
60 Beds

Mrs. Billie Speck-Administrator

MEDiCENTER PSYCHIATRIC
HOSPITAL

1505 Eighth Wichita Falls, Texas 76301

Services Available

• Psychotherapy Individual and Group

• Chemotherapy

• Recreational Therapy

• Occupational Therapy

• Psychological Testing

• Psychiatric Social Worker Services

• Neurological Consultation

• Electro-Convulsive Therapy

• Clinical Laboratory

• X-ray

• Pharmacy

• Physical Therapy

• Medical Consultations

Journal / April 1975 / Volume 68

133

BEVERLY HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

PSYCHIATRY

Jackson H. Speegle, MD Fred H. Jordan, MD

John T. Holbrook, MD Joseph H. Lindsay, MD

PSYCHOLOGY DIRECTOR OF NURSES

George R. Mount, PhD Tom I. Payton, MS Nita Ivey, RN

Donald L. Whaley, PhD Patrick R. Barnes, MS

O.T. AND R.T. ACTING DIRECTOR

EDUCAilON DIRECTOR Jeanette Boothe

William E. Nix, PhD COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

134

Oklahoma State Medical Association

Technical Exhibitors

The Technical Exhibits of the Oklahoma Medical Summit may be seen in the Exhibit Area
of the Lincoln Plaza Forum.

Abbott Laboratories
Academy Computing Corporation
Audio Equipment Company
Armour Pharmaceutical Company
Association of American Physicians and
Surgeons

Ayerst Laboratories

Don Bernard’s Indian Jewelry

Beverly Hills Hospital Inc.

R. K. Black, Inc.

Blue Cross-Blue Shield Plans of Oklahoma
Bristol Laboratories
Boehringer Ingelheim Ltd.

Burroughs Wellcome Company
Ciba Pharmaceutical Company
Cooper Laboratories, Inc.

Coyne Campbell Hospital
Credit Service
Danal Laboratories
Dow Pharmaceuticals
Eaton Laboratories
The Emko Company
Fisons Corporation
Fuller Laboratories
Geigy Pharmaceuticals
Health Care Management
Hoechst Corporation
Hospital Products, Inc.

International Medical Electronics, Ltd.
Ives Laboratories, Inc.

Lederle Laboratories

Eli Lilly and Company
Mallinckrodt, Inc.

Marion Laboratories, Inc.

Mead Johnson Laboratories
Medco Products Company
Medical Plastics Laboratory, Inc.
Merrell-N ational Laboratories
Metro Med Inc.

Meyer Laboratories, Inc.

Mission Pharmacal Company
Ortho Pharmaceutical Corporation
Parke, Davis and Company
Pfizer Laboratories
Professional Corn-Data Corporation
Riker Laboratories, Inc.

A. H. Robins Company
Roche Laboratories
Roerig

Wm. H. Rorer, Inc.

Ross Laboratories

Sandoz Pharmaceuticals

Searle Laboratories

Smith Kline and French Laboratories

E. R. Squibb and Sons, Inc.

Stuart Pharmaceuticals

Tri-State Pharmaceuticals Company

USV Pharmaceutical Corporation

Upjohn Company

Wallace Laboratories

Wang Laboratories

Webcon Pharmaceuticals

Wyeth Laboratories

TELEPHONE MESSAGE

While physicians are attending the Oklahoma Medical Summit in Oklahoma
City, emergency calls may be referred to:

525-8244

A courtesy message center will be maintained during Oklahoma Medical
Summit in the Lincoln Plaza Forum Exhibit area.

Journal / April 1975 / Volume 68

135

DOCTOR, WHAT WILL YOU EARN?

It depends, of course, on your age and annual earnings, but the amount can quite reasonably
exceed $400,000.

Is this logical? Not when you can participate in the . . .

O.S.M.A. GROUP DISABILITY INCOME PROGRAM

Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION
. . . gives you individual coverage at low group rates.

. . . offers flexible waiting periods at your option.

. . . guarantees you an income when you are disabled from an accident or sickness.

. . . offers optional Indemnity from $200.00 to $2,500.00 per month.

. . . pays for lifetime on accident and up to age 65 on sickness.

For Additional Information, call or write

Jim Thaxton, Bill Howard or Rodman A. Frates
C. L FRATES & COMPANY, INC.

720 N.W. 50th P.O.Box 18695
OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848-7661

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance

Springfield, Mass.

For additional details and application form, please contact

Jim Thaxton

Administrator

720 N.W. 50th Telephone 405 848-7661

P-O. Box 18593 Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

136

Oklahoma State Medical Association

PROGRAM

All events will be held in the Lincoln Plaza Forum unless otherwise
noted.

Wednesday Morning, April 23rd

9:00 am OSMA BOARD OF TRUSTEES. The annual business meet-
ing of the medical association’s Board of Trustees will be held in
the Lincoln Plaza’s Rotunda Room.

12:00 noon OSMA TRUSTEES LUNCHEON.

12:00 noon OAFP DIRECTORS LUNCHEON.

Wednesday Afternoon, April 23rd

1:00 pm OAFP BOARD OF DIRECTORS. The annual meeting of the
Oklahoma Academy of Family Physicians Board of Directors
will be held in the Lincoln Plaza’s Rotunda Room.

2:30 pm OSMA HOUSE OF DELEGATES. The opening session of the
OSMA’s House of Delegates will be held in the Lincoln Plaza’s
Congress Room.

6:00 pm EARLY BIRD PARTY. The first social event during Oklahoma
Medical Summit ’75 will be the Early Bird Party. It will start
with a cocktail reception at 6:00 pm in the Lincoln Plaza Hotel’s
Congress Room. At 7:00 pm the party will move to the Lincoln
Plaza Playhouse for dinner and a play. The play, starring Joseph
Cotton, will be "The Reluctant Debutante.” Tickets are $12.50
per person.

Thursday Morning, April 24th

7 :30 am GENERAL REGISTRATION. General Registration for Okla-
homa Medical Summit ’75 will be in the lobby area of the Lincoln
Plaza Forum Building.

8:00 am OSMA REFERENCE COMMITTEES. The three Reference
Committes of the OSMA House of Delegates will meet in assigned
rooms in the Lincoln Plaza Forum Building. All members of the
association are invited to attend.

oijrnal / April 1975 / Volume 68

137

8:30 am

OBSTETRICAL EMERGENCIES. The Oklahoma City Ob-
stetrical and Gynecological Society has invited Lee B. Stevenson,
MD, Grace Hospital, Detroit, Michigan, to be its guest speaker.
He will be joined by Oklahoma City’s Warren Crosby, MD.

8 :30 am

ANSWERS ABOUT MEDICARE. Consultants from the
Aetna-Medicare Claims Administration will be available for all
three days of Oklahoma Medical Summit ’75 to answer your ques-
tions about Medicare. These will not be formal presentations,
but informal consultations with members of individual physician
offices.

9:00 am

DEFICIENCIES OF IMMUNITY. This half-day session is
being planned by the Oklahoma Society of Internal Medicine.
Out-of-state guest speaker will be Alexander Lawton, MD, As-
sociate Professor of the Department of Pediatrics, University of
Alabama Medical Center, Birmingham. Topics will include
"Humoral Immune Deficiencies: A Spectrum of Defects in
B-Lymphocyte Differentation,” "Chronic Mucocutaneous Cardi-
diasis” and "Cellular Immune Deficiency and Granulocyte De-
ficiencies.”

12:00 noon SUPERSTAR LUNCHEON. Guest speaker for the Thursday
Luncheon will be Herbert Holden, MD, President of the American
Academy of Family Physicians. Tickets are $5 per person.

Thursday Afternoon, April 24th

2:00 pm BURNS IN MEDICAL PRACTICE. A symposium on mod-

2:00 pm

ern burn therapy is being offered by the Oklahoma Surgical Asso-
ciation. Out-of-state guest speaker will be Charles R. Baxter,
MD, Professor of Surgery, Southwestern College, Dallas. His
subject will be "Triage, First Aid and Resuscitation.” Other top-
ics will include "Modern Burn Therapy in Primary Practice,”
"Care of Burn Wounds — Major and Minor” and "The Burn
Nurse — Solutions to Problems of the Burned Patient and Their
Physician.” Other guest speakers will include E. Ide Smith, MD;
Paul Silverstein, MD; and Ms. M. Victery, RN.

ALLERGY. An afternoon session is being sponsored by the Okla-
homa Allergy Society. Topics will include "Clinical Applica-
tions of Newer Immunologic Procedures” and a panel discussion
on "Bronchial Asthma — What’s New!”

2:00 pm

ADVANCES IN PERINATOLOGY. Four physicians will
make up a special program sponsored by the Oklahoma Society
of Pediatrics. Sheldon B. Korones, MD, Professor of Pediatrics,
University of Tennessee College of Medicine, Memphis, will
be a featured out-of-state speaker. He will be joined by LeRoy
C. Mims, MD, and John J. VanHoutte, MD, both of Oklahoma.
Topics will include "Respiratory Distress Syndrome — Recog-
nition, Management, and Pitfalls,” "Metabolic Adjustments in
High Risk Newborns,” "Radiological Interpretations of Infants
at High Risk and Respiratory Distress Syndrome” and "Results
of Management of High Risk Infants Treated in Intensive Care
Units.”

138

Oklahoma State Medical Association

5:00 pm DOUBLEHEADER PARTY. Oklahoma Medical Summit ’75
is putting on a doubleheader party on Thursday afternoon. A
Keg and Oyster Party is being sponsored by Marion Laboratories.
At the same time there will be a Wine and Cheese Tasting Party.
Both will be in the Lincoln Plaza Hotel’s Congress Room.

Friday Morning, April 25th

9:00 am OSMA HOUSE OF DELEGATES. The closing session of the
OSMA’s House of Delegates will be held Friday morning in the
Lincoln Plaza Hotel’s Lincoln Room. Election of officers and final
consideration of all reports and resolutions will be the order
of business.

9:00 am CANCER OF THE PROSTATE. A full-day seminar on cancer
is being sponsored by the Oklahoma Division and Oklahoma
County Unit of the American Cancer Society. The morning will
be devoted to cancer of the prostate. Out-of-state speakers in-
clude George T. Mellinger, MD, Chief of Urology, Veteran’s Ad-
ministration Hospital, Wichita, Kansas and Donald F. Gleason,
MD, Professor of Pathology and Laboratory Medicine, University
of Minnesota, Minneapolis. Topics to be covered in the morning
include "Approach Toward International Classification of Car-
cinoma of the Prostate . . .,” "National Cooperative Studies of
Carcinoma of the Prostate,” "Combined Pathological Grading
and Clinical Staging Relative to Prognosis in Carcinoma of
the Prostate,” "Radiation Therapy — A Curative Modality,”
and "Oklahoma Regional Study of Carcinoma of the Prostate.”

9:00 am PSYCHIATRY SEMINAR. The Oklahoma District Branch
of the American Psychiatric Association is sponsoring a pot-
pourri program for psychiatrists. Topics will include "Cardio-
vascular and Neuroendocrine Concomitants of Sleep States,”
"Use of Hypnosis in Medical Practice: Shall We Lose Sleep Look-
ing for Prescription Drugs to Induce Sleep?,” "Pharmacokinetics
and the Faith of Psychoactive Medication in Body Systems: Steps
Toward a Rational Use of Drugs,” "Side Effects of Drugs Com-
monly Used for Nervousness” and a special lecture on "Chal-
lenges and Strategies in the Rational Treatment of Depres-
sion.” This last will be given by George N. Simpson, MD, Princi-
pal Research Scientist, Rockville State Hospital, Orangeburg,
New York.

12:00 noon SUPERSTAR LUNCHEON. One of the nation’s most sought-
after physician speakers will be featured at the Friday Luncheon.
Phillip Thorek, MD, will be the guest speaker.

Friday Afternoon, April 25th

1:30 pm ACUTE MYOCARDIAL INFARCATION. An afternoon
session devoted to new concepts in the managements of MI is be-

Journal / April 1975 / Volume 68

139

ing sponsored by the Oklahoma Heart Association. The all-Okla-
homa physician panel will discuss such topics as "New Efforts
to Diminish the Magnitude of Muscle Necrosis in the Management
of Acute Myocardial Infarction,” "Cardiogenic Shock — Defini-
tion and Management,” "Invasive and Noninvasive Monitoring
in the Coronary Care Unit,” "Ventricular Arrhythmias in the
CCU — Do All of Them Need Therapy?,” "Bradyarrhythmias in
the CCU — Which Ones Require A Temporary Pacemaker?”
and the session will end with a question and answer panel dis-
cussion.

2:00 pm CANCER SEMINAR. The afternoon portion of the American
Cancer Society’s program will feature three out-of-state speak-
ers: Gordon F. Schwartz, MD, Associate Professor of Surgery
and Director of Clinical Services, Breast Diagnostic Center,
Jefferson Medical College, Philadelphia; Lee B. Stevenson,
MD, Chief of the Division of Obstetrics and Gynecology, Grace
Hospital, Detroit; and C. G. Coin, MD, Radiology Associates in
Albuquerque, New Mexico. Topics will include "Detection and
Treatment of Early Breast Cancer,” "Cancer of the Uterus,”
"Computerized Axial Tomography in Brain Tumors,” "Experi-
ence with Trans-Bronchial Biopsy” and "Flexible Fiberoptic
Bronchoscopy in the Diagnosis of Lung Carcinoma.”

2:00 pm RENAL PATHOLOGY. "Some Myths of Chronic Pyelonephri-
tis” will be the subject of a lecture by Robert H. Heptinstall, MD,
Chairman of the Department of Pathology, The Johns Hopkins
School of Medicine, Baltimore. The session is being sponsored
by the Oklahoma State Association of Pathologists.

6:30 pm PRESIDENTS’ DINNER-DANCE. The presidents and presi-
dents-elect of the three sponsoring organizations for Oklahoma
Medical Summit ’75 will host the annual Presidents’ Dinner-
Dance on Friday Evening. It will start at 6:30 pm with a cocktail
reception in the Lincoln Plaza Hotel Congress Room. At 7:00
pm dinner will be served in the Lincoln Plaza Playhouse (the
play will not be offered this evening). The official ceremonies
will be kept brief and a dance will start at 8:30 pm. Music will
be furnished by the Forrest Wasson Orchestra. Tickets are $15
per person.

Saturday Morning, April 26th

8:30 am HYPERLIPOPROTEINEMIAS. Oklahoma’s Medical Re-
search Foundation is sponsoring a half-day program on "Clinical
Significance of the Hyperlipoproteinemias and Their Manage-
ment.” Out-of-state guest speaker will be William R. Hazzard,
MD, Director, Northwest Lipid Research Clinic, Seattle, Wash-
ington. His topic will be "Treatment of Hyperlipoproteinemias.”
Other topics will include "The Clinical Significance of the Hyper-
lipoproteinemias,” "Cardiovascular Diagnosis and its Role in
Evaluation of Hyperlipoproteinemias” and a panel discussion
on 'Diagnostic and Therapeutic Problems of the Hyperlipo-
proteinemias.”

140

Oklahoma State Medical Association

8:30 am

9:00 am

11:30 am

ANESTHESIOLOGY. The Oklahoma Society of Anesthes-
iologists has invited Herman Turndorf, MD, Professor and Chair-
man of the Department of Anesthesiology, New York University
School of Medicine to be their guest speaker. His subject will
be "Anesthesia for Ophthalmic Surgery,” and "Tracheal Lesions
Following Airway Intubation.”

ORTHOPEDICS AND RHEUMATISM. The Oklahoma Or-
thopedic Society and the Oklahoma Rheumatism Society will
combine to offer a half-day program on such topics as "Arthro-
plasty of the Hip and Knee,” "Care of Acute Injuries of the Hand,”
"Athletic Injuries of Soft Tissue,” "Polymyalgia Rheumatica,”
"Dermatomyositis and Polymyositis” and "Rheumatoid Arth-
ritis.” Out-of-state speakers will be Charles A. McKenna, MD,
Assistant Professor of Medicine, Mayo Clinic, Rochester, Min-
nesota; and Robert H. Persellin, MD, Professor of Medicine and
Chairman of the Division of Rheumatology, University of Texas
Medical School, San Antonio.

UROLOGY. The Oklahoma State Urological Association will
sponsor a discussion of such topics as "Stage D Carcinoma of the
Prostate,” "Correlation of Metastasis with Pathological Grade
and Clinical Stage,” "Orchiectomy and Estrogens; the Veteran’s
Administration Experience,” "Hypophysectomy,” "Cytoxan
and Other Drugs” and "Radiation Therapy, Including P-32.”

SUPERSTAR LUNCHEON. Saturday’s Superstar Luncheon
will feature two outstanding speakers: Governor David L. Boren
of the State of Oklahoma and Joe T. Nelson, MD, American
Medical Association Trustee. Luncheon tickets are $5 per person.

Saturday Afternoon, April 26th

1:30 pm PHOTOGRAPHY SEMINAR. A special seminar for amateur
photographers will be conducted by an Oklahoma City commer-
cial photographer, David Fitzgerald, and an amateur interna-
tional salon exhibitor, Raymond Riggs. They will discuss all
aspects of amateur photography.

2:00 pm PSRO. Guest speaker at this special meeting will be Henry E.

Simmons, MD, MPH, Director of HEW’s Office of Professional
Standards Review. His presentation will be followed by a panel
discussion featuring Joe T. Nelson, MD, American Medical As-
sociation Trustee; Herbert A. Holden, MD, American Academy
of Family Physicians President; and Doctor Simmons.

5:00 pm ORTHOPEDICS AND RHEUMATISM. This is a continuation
of the morning program sponsored by the Oklahoma Orthopedic
Society and the Oklahoma Rheumatism Society. Two topics
will be discussed, "Work in Progress: Rheumatology at the Mayo
Foundation” and "Research Project Report.” □

Journal / April 1975 / Volume 68

141

Summit ’75 Entertainment

Joseph Cotton

DOUBLEHEADER PARTY

5:00 pm— -Thursday, April 24th

The Summit ’75 doubleheader will be a Keg
and Oyster Party combined with a Wine and
Cheese Tasting Party. Marion Laboratories
will sponsor the Keg and Oyster portion of the
affair and will dish out delicacies from the
briney deep and cooling brew. For those with
a more refined pallet, wine and cheese will be
available.

The party starts early so there will be time
for a night on the town, specialty dinners, or
alumni functions.

142

EARLY BIRD PARTY

6:00 pm — Wednesday, April 23rd

Medical Summit’s Early Bird Party will fea-
ture a cocktail reception at 6:00 pm followed by
dinner and a play at 7:00 pm in the Lincoln
Plaza Playhouse. The play for the evening will
be "The Reluctant Debutante” starring Joseph
Cotton. Tickets for the Early Bird Party are
$12.50 per person.

PRESIDENTS’ DINNER-DANCE

6:00 pm-— Friday, April 25th

The Presidents’ Dinner-Dance will honor the
outgoing and incoming presidents of Okla-
homa Medical Summit’s three sponsoring or-
ganizations: The Oklahoma Academy of Fam-
ily Physicians, Oklahoma City Clinical Soci-
ety, and the Oklahoma State Medical Associa-
tion. Cocktails and hors d’oeuvres will be fea-
tured from 6:00 until 7:00 pm, in the Lincoln
Plaza Hotel’s Congress Room. This will be fol-
lowed by dinner in the Lincoln Plaza Play-
house (the play will not be offered this eve-
ning.) A gourmet menu has been arranged and
will be served with appropriate wine. The offi-
cial ceremonies for the evening will be brief
and followed, at 8:30 by a dance. Music will be
furnished by the Forrest Wasson Orchestra.
Tickets for the function are $30 per couple ($15
per person). D

Oklahoma State Medical Association

Summit Superstar Luncheon Speakers

Three nationally recognized experts from the socioeconomics of medical care will be luncheon
speakers during Oklahoma Medical Summit ’75. Each luncheon will start at 12 noon, Thursday
through Saturday, in the Lincoln Plaza Forum Room (downstairs). Tickets are $5 per person, per
luncheon.

THURSDAY LUNCHEON

SPEAKER, HERBERT HOLDEN, MD

Doctor Holden is the current President of the
American Academy of Family Physicians.

FRIDAY LUNCHEON

SPEAKER, PHILLIP THOREK, MD

Doctor Thorek is one of the most sought after
physician-speakers in the United States. He is
director of Medical Education for the American
Hospital in Chicago.

SATURDAY LUNCHEON

SPEAKERS, GOVERNOR DAVID L. BOREN AND JOE T. NELSON, MD

The Saturday luncheon will feature two speakers. Governor David L. Boren (left), Governor of
the State of Oklahoma, will join Joe T. Nelson, MD, American Medical Association Trustee. Doctor
Nelson is an internist in general practice in Weatherford, Texas. □

Journal / April 1975 / Volume 68

143

AGENDA*

House of Delegates Meeting

ANNUAL MEETING — OPENING SESSION

2:30 pm, Wednesday, April 23rd, Lincoln Room, Lincoln Plaza Hotel

Call to Order

VII.

Board of Trustee’s Report

II.

Report of Credentials Committee

VIII.

Treasurer’s Report

III.

Introduction of Guests

IX.

Council and Committee Reports

IV.

Remarks of Speaker

Introduction of Resolutions

Nominations for Elections

Necrology Report

VI.

Report of the President

(Reference Committees will meet at 8:00 am on Thursday morning, April 24th,

in the Lincoln Plaza Forum Building.)

ANNUAL MEETING— CLOSING SESSION

9:00 am, Friday, April 25th, Lincoln Room, Lincoln Plaza Hotel

I. Call to Order IV. Elections

II. Report of Credentials Committee V. Adjournment

III. Reference Committee Reports

* Condensed version subject to modification

OFFICERS TO BE ELECTED

President-Elect (one-year term)

Vice-President (one-year term)

Secretary-Treasurer (two-year term)

Delegate to AMA, position three (two-year term)

Alternate Delegate to AMA, position three (two-year term)

Trustees from District XI through XIV (three-year term)

Photo Contest and Photography Seminar

Physicians and spouses interested in photo-
graphy are invited to enter the Oklahoma Med-
ical Summit ’75 Photo Contest to be held during
the April 23rd-26th meeting in the Lincoln
Plaza Forum.

In addition to the contest, there will also be a
Photography Seminar on Friday afternoon,
April 26th for amateur photographers. The
seminar will be taught by Mr. Raymond Riggs,
an international amateur salon exhibitor, and
Mr. David Fitzgerald, a commercial photo-
grapher in Oklahoma City. The two men will
present a formal program and then leave time
for questions and answers.

The rules for the photography contest are as
follows:

Rule 1: All entrants must be members of at
least one of the sponsoring organizations of
Oklahoma Medical Summit (OAFP, OCCS, or
OSMA) or the spouse of a member.

Rule 2: Entries may be either black and white
or color prints with a minimum size of 5 x 7
inches up to a maximum size of 16 x 20 inches.

144

All photos must be mounted or framed. (Sorry,
no slides or transparencies.)

Rule 3: Photos may be of any subject matter:
portrait, scenic, general interest, scientific, etc.

Rule 4: All entries must be in the Oklahoma
State Medical Association office no later than
Monday, April 21st. . .or entries may be
brought to the Lincoln Plaza Forum Building on
Wednesday afternoon, April 23rd.

Rule 5: Each entry must be clearly marked so
that its ownership may be easily ascertained.
All photos will be returned to their owners after
the Oklahoma Medical Summit meeting, or
they may be picked up on Saturday afternoon,
after 4:00 pm, April 26th.

Rule 7: First, second, and third place awards
of $75, $50 and $25 gift certificates will be made
for the best three black and white and three
color photos.

All entries should be shipped to Oklahoma
State Medical Association, Attention Ed Kel-
say, 601 Northwest Expressway, Oklahoma
City, Oklahoma 73118. □

Oklahoma State Medical Association

1975 Delegates and Alternates

SOCIETY

ALFALFA-WOODS
ATOKA-BRYAN-COAL
BECKHAM (Roger Mills)
BLAINE
CADDO
CANADIAN
CARTER-LOVE-
MARSHALL
CHOCTAW-
PUSHMATAHA
CLEVELAND-McCLAIN

COMANCHE-COTTON-

TILLMAN

COOKSON HILLS
(Cherokee, Adair &
Sequoyah)
CRAIG-OTTAWA-
DELAWARE
CREEK
CUSTER
EAST CENTRAL

GARFIELD

GARVIN-MURRAY

GRADY

GREER-HARMON

HUGHES-SEMINOLE

JACKSON

JEFFERSON

KAY-NOBLE

KINGFISHER

KIOWA/WASHITA

LeFLORE-HASKELL

LINCOLN

LOGAN

McCURTAIN

NORTHWEST

(Beaver, Dewey, Ellis,
Harper & Woodward)
OKFUSKEE
OKLAHOMA

DELEGATE

John X. Blender, MD
(Not Reported)

Wm. M. Leebron, MD
Billy Dale Dotter, MD
Arvin C. Roberson, MD
Edgar W. Young, MD
David P. Rose, MD
Edward E. Velayos, MD
(Not Reported)

Chester L. Bynum, MD
James B. Silman, MD
Hayden H. Donahue, MD
Robert Hillis, MD
Jack D. Honaker, MD
Samuel C. Jack, MD
William Z. Cook, Jr., MD

Yale E. Parkhurst, MD

(Not Reported)

James Harold Tisdal, MD
Edward H. Fite, Jr., MD
M. C. Gephardt, MD
Harvey P. Randall, MD
Edward L. Leonard, MD
Joseph W. Stafford, MD
Joe B. Jarman, Jr., MD
Frank L. Adelman, MD
John W. Ellis, MD
J. William McDoniel, MD
Wade Norman, MD
Jack W. Parrish, MD
Charles L. Tefertiller, MD
Malcolm Mollison, MD
(Not Reported)

Edwin C. Yeary, MD
Jack L. Berry, MD
(Not Reported)

R. L. Winters, MD
(Not Reported)

Robert F. Ringrose, MD
(Not Reported)

(Not Reported)

Donald D. Albers, MD
Charles Atkins, MD
H. Thompson Avey, MD
Jack H. Barney, MD
Wm. G. Bernhardt, MD
Karl K. Boatman, MD
Kent Braden, MD

ALTERNATE DELEGATE

Ed L. Calhoon, MD
(Not Reported)

(Not Reported)

Claude H. Williams, MD
James A. Hill, MD
James P. Jobe, MD
Winfred L. Medcalf, MD
J. Hobson Veazey, MD
(Not Reported)

Frank H. Cooper, MD
James S. Wall, MD
John G. Rollins, MD
J. Paul Reimer, MD
William S. Davies, MD
C. Victor Williams, MD
Clifford A. Traverse, MD

(Not Reported)

John M. Huser, MD
Jesse S. Chandler, MD
Tom G. Hodge, MD
David F. Watson, MD
Wm. S. Dandridge, MD
Earl M. Robinson, MD
Gene Stunkle, MD
Paul A. Leap, MD
James H. Lindsey, MD
(Not Reported)

Phillip N. Kingery, MD
Claude B. Knight, MD
Noble Ballard, MD
Noble Ballard, MD
(Not Reported)

E. Edwin Fair, MD
Kenneth Evans, MD
(Not Reported)

C. D. Cook, MD
(Not Reported)

J. R. Henke, MD
(Not Reported
(Not Reported)

(Not Reported)

Martin H. Andrews, MD
Schales L. Atkinson, MD
A. Stanley Bailey, MD
Paul A. Bennett, MD
R. LeRoy Carpenter, MD
Wm. O. Coleman, MD
William J. Craig, MD

Journal / April 1975 / Volume 68

145

OKMULGEE

OSAGE

PAYNE-PAWNEE
PITTSBURG (Latimer)

PONTOTOC (Johnston)

POTTAWATOMIE

ROGERS-MAYES

STEPHENS

TEXAS-CIMARRON

TULSA

WASHINGTON-

NOWATA

Earl Bricker, MD
Irwin H. Brown, MD
R. Barton Carl, MD
Donald R. Carter, MD
Charles W. Cathey, MD
Wm. R. Cleaver, MD
Charles E. Delhotal, MD
Richard G. Dotter, MD
John W. Drake, MD
Arthur F. Elliott, MD
Warren L. Felton, II, MD
Thomas H. Henley, MD
Elwood Herndon, MD
Wm. E. Hood, Jr., MD
Daniel M. Lane, MD
James E. Mays, Jr., MD
Robt. A. McLauchlin, MD
Willard B. Moran, Jr., MD
James B. Pitts, MD
Don E. Rhinehart, MD
Clarence Robison, Jr., MD
W. W. Sanger, MD
Arthur E. Schmidt, MD
Armond H. Start, MD
Stephen Tkach, MD
Ronald H. White, MD
Kenneth Whittington, MD
Neil W. Woodward, MD
C. Jack Young, MD

T. C. Alexander, MD
(Not Reported)

(Not Reported)

Kenneth R. Miller, MD
George M. Brown, Jr., MD

(Not Reported)

M. R. Jennings, MD
James S. Jones, MD
(Not Reported)

C. S. Lewis, Jr., MD
Floyd F. Miller, MD
Robert L. Imler, Jr., MD
Robert M. Shepard, Jr., MD
Lynwood Heaver, MD
Henry H. Modrak, MD
E. N. Lubin, MD
Robert G. Perryman, MD
Robert K. Endres, MD
R. W. Goen, MD
William E. Hall, MD
Hall Ketchum, MD
Donald F. Mauritson, MD
Richard E. McDowell, MD
Rollie E. Rhodes, Jr., MD
Edward K. Norfleet, MD
Roger V. Haglund, MD
James E. White, MD
Frank A. Clingan, MD
David Browning, Jr., MD
Fred R. Martin, MD

Carl H. Guild, MD
Vernon M. Lockard, MD
Hillard E. Denyer, MD

M. Joe Crosthwait, MD
Ernest R. Daffer, MD
W. Edward Dalton, MD
Ronald C. Elkins, MD
Robert S. Ellis, MD
Paul D. Erwin, MD
James D. Funnell, MD
James R. Geyer, MD
James F. Hammarsten, MD
James W. Hampton, MD
Charles M. Harvey, MD
George R. Jay, MD
Edmond H. Kalmon, MD
Neil B. Kimerer, MD
Robert D. Lindeman, MD
Ralph R. Markland, MD
Billy J. Matter, MD
Stanley R. McCampbell, MD
Wm. G. McCreight, MD
Jerry R. Nida, MD
William R. Paschal, MD
Donald G. Preuss, MD
William B. Renfrow, MD
Edwin E. Rice, MD
S. S. Sanbar, MD
Marcus B. Shook, MD
Louis E. Speed, MD
Frank F. Wilson, III, MD
Dan E. Woodson, MD

Robert L. Alexander, Jr., MD
(Not Reported)

(Not Reported)

Thurman Shuller, MD
C. E. Lively, MD

(Not Reported)

Randel A. Patty, MD
Gerald L. Beasley, Jr., MD
(Not Reported)

R. Wayne Neal, MD
David H. Copple, MD
Perry F. Crawford, MD
Robert L. Anderson, MD
A. Paul Compton, MD
Jerry Sisler, MD
Gerald E. Gustafson, MD
Daniel R. Storts, MD
Stephen J. Adelson, MD
Robert L. Scott, MD
Richard G. Williams, MD
Dixon N. Burns, MD
Martin Leibovitz, MD
Byron W. Steele, Jr., MD
C. William Simcoe, MD
H. Kenneth Ihrig, MD
Marcel Binstock, MD
Theodore R. Wenger, MD
Homer D. Hardy, Jr., MD
Bryce O. Bliss, MD
Thomas L. Ashcraft, MD
John R. Drum wright, MD
Elvin M. Amen, MD
John R. Reid, Jr., MD

146

Oklahoma State Medical Association

WOMAN’S AUXILIARY

to the

Oklahoma State Medical Association

ANNUAL CONVENTION PROGRAM

April 23rd, 24th, 25th, 26th, 1975

Oklahoma City, Oklahoma

Lincoln Plaza Forum

MRS. JOHN W. WILLIAMS
Enid

President

MRS. ERLE E. WILKINSON
Nashville, Tennessee
President-Elect, Auxiliary
to the American Medical
Association

MRS. WILLIAM B. RENFROW
Oklahoma City
President-Elect

MRS. JAMES H. MANNING
Marietta, Georgia
President, Auxiliary to the
Southern Medical Association

Journal / April 1975 / Volume 68

147

MRS. MICHAEL BROWN
Ardmore

First Vice-President

MRS. NEIL B. KIMERER
Oklahoma City
Treasurer

MRS. SCOTT HENDREN
Oklahoma City
Second Vice-President

MRS. EARL M. BRICKER
Oklahoma City
T reas u re r-E led

MRS. JOSEPH W. STAFFORD
Enid

Recording Secretary

148

Oklahoma State Medical Association

GENERAL INFORMATION

REGISTRATION

BLUE ROOM

Wednesday, April 23rd 1:00 pm-5:00 pm

Thursday, April 24th 8:30 am-5:00 pm

Friday, April 25th 8:30 am-5:00 pm

Saturday, April 26th 8:30 am- 12 noon

HOSPITALITY
BLUE ROOM

This room will be open during registration hours,
Wednesday, Thursday, Friday and Saturday for
the convenience of the guests. Refreshments will
be served.

DOCTORS’ DAY EXHIBITS
BLUE ROOM

Wednesday, Thursday, Friday, Saturday

CONVENTION COMMITTEE

CHAIRMAN: Mrs. Karl K. Boatman
CO-CHAIRMAN: Mrs. Robert C. Brown

Credentials Mrs. Frank G. Gatchell

Decorations Mrs. Herbert P. Reinhardt

Luncheon-Book Review . . .Mrs. Marion C. Wagnon
Spirit of ’76 Awards

Luncheon Mrs. Richard B. Price

Public Relations Mrs. Virgil Ray Forester

Registration and

Hospitality Mrs. Jerry L. Bressie

Tickets Mrs. Daniel R. Stough

Transportation Mrs. David B. Brinker

CALENDAR OF EVENTS

Wednesday, April 23rd

1:00 pm Registration Opens

Set up exhibits

6:00 pm Social Hour

7:00 pm Dinner and Show

Thursday, April 24th

8:30 am-5:00 pm Registration

11:00 am Bus leaves for Petroleum Club

11:30 am-l:30 pm Luncheon & Book Review

1:00 pm-2:30 pm Loan Fund Meeting

2:30 pm-4:30 pm . . .Pre-Convention Board Meeting
5:00 pm Keg & Oyster Party

Friday, April 25th

8:00 am Past Presidents’ Breakfast

8:30 am-5:00 pm Registration

9:00 am-12 noon House of Delegates

12:30-2:30 pm Spirit of ’76 Awards

Luncheon — Fashions by Balliets

6:00 pm Social Hour

7:00 pm Dinner-Dance

Saturday, April 26th

8:30 am-12 noon Registration

8:30 am-ll:00 am Post-Convention Board

Meeting

9:30 am-ll:30 am Tour of Red Ridge

Art Museum

11:30 am Lunch with husbands

Governor David L. Boren and

Joe T. Nelson, MD, AMA Trustee, Speakers

ADVISORS

OKLAHOMA STATE MEDICAL ASSOCIATION

William M. Leebron, MD, Elk City
Orange M. Wellborn, MD, Ada
Avery B. Wight, MD, Enid

TELEPHONE MESSAGE

While physicians are attending the Oklahoma Medical Summit in Oklahoma
City, emergency calls may be referred to:

525-8244

A courtesy message center will be maintained during Oklahoma Medical
Summit in the Lincoln Plaza Forum Exhibit area.

Journal / April 1975 / Volume 68

149

DEATH

W. ARTHUR HYDE, MD
1901-1975

A long-time Durant surgeon, W. Ar-
thur Hyde, MD, 73, died February
27th, 1975. A native of Cleburne,
Texas, Doctor Hyde was graduated
from the University of Texas School of
Medicine in 1926. After practicing in
Galveston, Doctor Hyde established his
practice in Durant where he remained
until his retirement in 1971.

Active in both medical and civic af-
fairs, Doctor Hyde had served as Presi-
dent of the Atoka, Bryan, Coal County
Medical Society and as a Councillor to
the Oklahoma State Medical Associa-
tion. His medical affiliations include
the American College of Surgeons and
the International College of
Surgeons. □

Book Reviews

Care of the High Risk Neonate. By M. H.
Klauss and A. A. Fanaroff. 358 pp. Philadel-
phia: W. B. Saunders Co., 1973
Neonatal care has been one of the most
rapidly advancing areas of pediatrics for the
last 15 years. Several books have appeared re-
cently in response to an obvious need for practi-
cal guidance on the management of the sick
newborn infant. This book was conceived as an
attempt to introduce house officers, medical
students, and nurses to the different require-
ments of the care of newly born infants. The
format is quite different from that of a standard
textbook in that each chapter is devoted to a
practical problem such as assisted ventilation,
neonatal infection, and others. The chapters
begin with a discussion of the physiologic back-
ground of the subject followed by a list of practi-
cal considerations. There is then a summary of
the features of the chief disease which causes
the problem and the discussion and this is fol-
lowed by a detailed guide to management.

A further lively feature of the book is the
frequent inclusion of comments on the text by
other experts. That these sometimes contradict
what has just been said may sound confusing;
however, it is an effective way of indicating the
uncertain and controversial parts of neonatal
care. The text also contains many useful graphs

150

and illustrations. The appendix is 48 pages long j
and contains a list of normal values for new- 1
borns, growth charts, and guides to assessments |
of various problems.

This is a very useful book and is to be recom-
mended. Harris D. Riley, Jr., MD

Genetic Disorders of the Endocrine
Glands. By David L. Rimoin and R. Neil
Schimke, pp 383, C. V. Mosby Company, St.
Louis, Missouri, 1971. $32.50
This book is divided into nine chapters which
catalogue the various endocrinopathies which
have a proved or suspected genetic basis. The
first chapter, "The Genetic Aspects of Clinical
Endocrinology” outlines the mechanisms of
gene action and modes of inheritance pertinent
to endocrinologic abnormalities. Thereafter
each chapter discusses the anatomy, em-
bryology, and normal function of a particular
endocrine gland such as the anterior pituitary,
pancreas, thyroid, etc.

A particularly interesting and informative
section is that on the genetics of diabetes mel- j
litus.

The main defect of the book is the brevity
with which many of the subjects are treated.
Only the most salient facts without a thorough
discussion is offered. Because of the highly
specialized topic, the book will be of little direct
benefit to the practicing pediatrician or medic-
al student, but will be of interest to those in-
volved in the clinical and research aspects of
endocrinology and metabolism. Harris D.
Riley, Jr., MD

Human Prolactin: Proceedings of the In-
ternational Symposium on Human Pro-
lactin, Brussels, June 12-14, 1973. Edited
by J. L. Pastels and C. Brobin. New York:
American Elsevoir Company. 340 pp. Price
$32.50.

This monograph contains 33 papers and dis-
cussions from the Proceedings of the Interna-
tional Symposium on Human Prolactin held in
Brussels in June 1973. These concern chemis-
try, morphology, receptors, assay methods,
comparative physiology of secretion,
pathophysiology of secretion in humans, mam-
mary carcinogenesis, and pharmacology. The
focus is chiefly on investigative interests. This
monograph will be of interest only to those con-
cerned with this topic. Harris D. Riley, Jr.,
MD □

Oklahoma State Medical Association

HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND

RAI TlMDPr

The

May

1975

Vol. 68, No. 5

of the Oklahoma State Medical Association

EDITORIAL BOARD

MARK R. JOHNSON, MD
Editor-in-Chief

HARRIS D. RILEY, Jr.,MD
Editor

CONTENTS

ROBERT G. TOMPKINS, MD
Editor

editorial

ERNEST LACHMAN, MD
C orresponditig Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

OFFICERS

ARNOLD G. NELSON, MD
President

WILLIAM M. LEEBRON, MD
Vice-President

Haven W. Mankin, MD
Secretary-Treasurer

Acromegaly Lurks!
President’s Page

151

152

scientific

Pancreatitis In Children, James Freed, MD, J. Rainer
Poley, MD, E. Ide Smith, MD, Adele Altman, MD
and Harris D. Riley, Jr. MD . . . . 153

Hypertension In Oklahoma County, S. S. Sanbar, MD,

PhD 165

News from the Oklahoma State Department of

Health ........ 169

STAFF

DON BLAIR
BusinessManager

LOUISE MARTIN
Editorial Assistant

SUBSCRlFI ION TO THE JOURNAL is included in
membership fees. Other subscriptions are
$6.50 per year or $1.00 per copy with each
request subject to approval of the Editorial
Board.

POSTMASTERS: Send all change of address
notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

news

Medical Summit ’75 Was ‘‘Biggest and Best” . 170

Utilization Review Regulations Incur Delegates’ Rath 170

Oklahoma Medical Summit ’75 ..... 172

Sixteen Resolutions Considered By House of Delegates 175

House Votes to Retain Mandatory AMA Membership 178

OSMA House Votes Dues Increase .... 180

Death 181

Arkansas-Oklahoma Cancer Forum Scheduled For

September . . . . . . . . 181

Summit Photo Contest Winners Announced . . 181

L. H. Becker, MD, To Be Honored .... 181

Braden Seeks New OMPAC Members . . . 181

Book Review ........ 182

Miscellaneous Advertisements ..... xi

Index To Advertisers ...... xxxvi

Woman’s Auxiliary ....... xxxvii

The Last Word xxxviii

(Cover Art By William Cason)

500341

One contains aspirin.
One doesn’t.

Dar vocet-N 100

100 mg. propoxyphene napsylate
and 650 mg. acetaminophen

Dar von
Compound-65

65 mg. propoxyphene hydrochloride,
227 mg. aspirin, 162 mg. phenacetin,
and 32.4 mg. caffeine

Additional information available to the profession on request.
Eli Lilly and Company, Inc., Indianapolis, Indiana 46206

Oklahoma State Medical Association

ACROMEGALY LURKS!

Growth hormone-producing lesions of the
hypothalamic-pituitary axis produce distinc-
tive changes in humans which we recognize as
acromegaly. The disease can kill through both
its central tumorous effects and through the
peripheral hormonal effects on the skeletal and
cardiovascular systems. When fully developed,
the signs of soft tissue and bony overgrowth
are extremely characteristic, but recognition is
often delayed for decades, principally because
the changes develop so slowly that neither pa-
tient, family nor family physician notices the
transformation even as it occurs before their
very eyes. Unfortunately, bony changes never
remit, and destructive changes due to central
nervous system tumors may also be irreversi-
ble. Early diagnosis is critical if the patient is
to be spared acromegalic disfigurement.

Although the cause of acromegaly remains
obscure (primary pituitary neoplasia vs
hypothalamic dysfunction causing hyper-
pituitarism), the disease is easily diagnosed by
determinations of serum human growth hor-
mone (HGH) concentrations and reliable as-
says are available from numerous commercial
laboratories within easy access to physicians.
In view of the seriousness of the disease, the
investment in two serum HGH determinations
(fasting and two hours after 100 gms of orally
administered glucose) is cheap indeed and is to
be strongly recommended. (Actual cost approx-
imately $20 per sample.) In acromegaly, there
is failure of the HGH concentration to sup-
press, after glucose, to less than 5 ng/ml.1 Fast-
ing HGH levels alone can be misleading be-

Journal / May 1975 / Volume 68

cause of the many normal stimuli for HGH re-
lease.

Major therapeutic improvements have ap-
peared during the past ten years and all physi-
cians should be aware that acromegaly is a
treatable, if not a curable, disease. The success-
ful removal of growth hormone-producing
tumors by transsphenoidal hypophysectomy
utilizing microdissection methods is particu-
larly impressive,2 and newer information
clearly shows significant improvement in
growth hormone concentrations following ex-
ternal irradiation as well.3 While the long
sought for medical treatment is not imminent,
agents are known which can ameliorate exces-
sive growth hormone secretion. Both growth
hormone inhibiting hormone (somatostatin)4
which has been synthesized and is available for
research, and bromocryptine,5 appear very
promising.

Acromegaly is a lurking, indolent, serious
illness that should no longer go unrecognized
or untreated. James L. Males, MD, Department
of Medicine, Oklahoma City Clinic and Clinical
Instructor, Section of Endocrinology , College of
Medicine, The University of Oklahoma Health
Sciences Center. □

REFERENCES

1. Cryer, P. E., Daughaday, W. H. and Coxe, W. S.: Diagnosis and Therapy of
Acromegaly. Arch. Int. Med. 135: 338-343, 1975.

2. Hardy, J. and Wigser, S. M.: Transsphenoidal Surgery of Pituitary Fossa
Tumors with Televised Radiofluoroscopic Control. J. Neuro. Surg. 23: 612-619,
1965.

3. Roth, Jessie, Gordon, P. and Bruce, K.: Efficacy of Conventional Pituitary
Irradiation in Acromegaly. N. Eng. J. Med. 282: 1385-91, 1970.

4. Yen, S. S. C., Siler, T. M. and DeVane, C.: Effect of Somatostatin in
Patients with Acromegaly. N. Eng. J. Med. 290: 935-938, 1974.

5. Liuzzi, A., Chiodini, P. G., et al : Decreased Plasma Growth Hormone (GH)
Levels in Acromegalics Following CB 154 (2-Br-A-Ergocryptine) Admin-
istration. J. Clin. Endocrin. 38: 910-912, 1974.

151

president's page

I accept the high of-
fice of President of the
Oklahoma State Medical
Association with a deep
sense of humility. I ac-
cept, too, the deep re-
sponsibility that goes with
it, and I shall seek your
continued help and con-
tinued guidance in the months ahead. My fel-
low physicians, our cause is too great for any
one man to feel worthy of it. I promise that
during the coming months I will exert tre-
mendous energy and thought to help bring
about another successful year. I shall continue
to work with and help develop all segments of
medicine.

Our state medical association should exist
only as it relates to the care of patients, but
this must include every aspect of health of the
community. We must continue to demonstrate
our respect for the patient as a person. We
must be able to present our community with
educated opinions, and be willing to take a
stand on important issues regardless of the
popular appeal.

During the past year, the work of our Presi-
dent, Doctor Jack Richardson, has been very
outstanding. He has worked with untiring
energy and the association owes him a debt of
gratitude.

The committees have functioned very com-
mendably during the past year. I want to
thank all of you who participated in the com-
mittee work, for this is the basis and back-
ground of our state medical association. The
work of two of our committees, I feel, has been
tremendously outstanding.

The Legislative Committee has done a
yeoman’s job during the past year, under the
direction of Doctor Barton Carl and under the
staff leadership of Mr. David Bickham. These
men, along with the other members of the
committee, have done a tremendous job.

The Medical School Liason Committee,
headed by Doctor C. S. Lewis, Jr. of Tulsa, has
done an outstanding job during the past year.

I want to acknowledge and thank the Aux-
iliary to the Oklahoma State Medical Associa-

152

tion. Their diligence and untiring work goes
on and we do appreciate it.

I want to pledge the Oklahoma State Medi-
cal Association’s continued support of the
Oklahoma Health Sciences Center, and their
administration. I want to extend a special wel-
come to Doctor William Thurman, the new
Provost of our Oklahoma Health Sciences
Center. Doctor Thurman, we pledge our sup-
port in every way, to you, and to our Health
Sciences Center.

I want to acknowledge the fine work of our
Dean, Doctor Tom Lynn, and his staff, and
pledge our continued support of the Oklahoma
University Medical School. I want to acknowl-
edge the fine work of our Oklahoma State
Health Department. Doctor LeRoy Carpenter
and his staff have turned our State Health De-
partment into a responsive and responsible or-
ganization, within the medical profession. We
are proud of it. We are happy to work with you
and we pledge our support.

I am deeply concerned about the Professional
Standards Review Organization law and the
Utilization Review regulations. These problem
areas continue to bother us, and the problems
with them continue to change from day to day;
but, fellow physicians, whatever the problems
may be, let it be the policy of our state associa-
tion, to fight all government and other third
party interference with every method at our
disposal. We of the medical profession must
continue to support whatever policy can de-
liver the best medical care possible to our pa-
tients of Oklahoma.

If I can leave but one message, let it be one of
togetherness and cooperation. I would strongly
recommend that we continue cooperation
among all physicians throughout our state. We
do have some differences of opinion but our
overall goals are the same. We must continue
to fight for a common goal that will continue to
give our patients the best medical care in the
world.

Let the practicing physicians, and the physi-
cians of the Oklahoma Health Sciences Center
join hands; let all specialists and generalists
unite — and work together to make Oklahoma
a better place in which to live and a better
place in which to practice medicine.

Once again I ask for a cooperative spirit
among physicians of our State. If we can join in
a truly united front, then success will be ours.

Oklahoma State Medical Association

scientific

PEDIATRIC GRAND ROUNDS

Pancreatitis In Children

Participants

JAMES FREED, MD
Chief Resident, Department of Pediatrics,
Children’s Memorial Hospital

J. RAINER POLEY, MD
Assistant Professor, Pediatric Gastroenterologist,
Children’s Memorial Hospital

E. IDE SMITH, MD
Professor, Department of Surgery, Chief, Pediat-
ric Surgery, Children’s Memorial Hospital

ADELE ALTMAN, MD
Associate Professor, Department of Radiology,
Children’s Memorial Hospital

HARRIS D. RILEY, JR., MD

Professor and Head, Department of Pediatrics,
Children’s Memorial Hospital

Pancreatitis in children is a relatively
uncommon disorder. This article reviews all
facets of this disorder with particular
emphasis on an unusual form,
hereditary pancreatitis.

Doctor Riley: The patient to be presented
demonstrates an unusual type of pancreatitis.
Of course, pancreatitis of any type in children

From the Children’s Memorial Hospital, University of Oklahoma Health Sci-
ences Center.

Journal / May 1975 / Volume 68

is relatively uncommon. Doctor Freed will give
us the history, Doctor Poley will discuss topics
relevant to pancreatitis, and Doctor Smith will
discuss the surgical management of pan-
creatitis and its complications.

Doctor Freed: The patient is D.A.B., a
14-year-old white girl from northeastern
Oklahoma. She was admitted to Children’s
Memorial Hospital approximately one week
ago because of recurrent and severe abdominal
pains of several months’ duration. Bouts of ab-
dominal pains initially had recurred about
every 6 to 12 months since the age of six or
seven years. She indicated that the pain was in
the epigastric area. There was no associated
fever, nausea or vomiting. Abdominal pains in-
itially were relieved by antacids and aspirin.
During the past two years, the attacks of ab-
dominal pain have become more frequent and
more severe. They were occurring once every
six to nine months; and definitely were aggra-
vated by meals, but there was no vomiting and
neither the patient nor the mother remember
any particulanfoods which could precipitate an
attack. Initially, there was no transmission of
pain and there was no history of diarrhea or
steatorrhea and no history of anemia. In June
1968, during one of these attacks of abdominal

153

Pancreatitis / FREED, et al

pain, a serum amylase determination was re-
quested by the referring physician; it was ele-
vated to 688u/100 ml (normal up to 160u/100
ml). During 1969, the patient had only one at-
tack and x-ray studies of the upper gastro-
intestinal tract that summer were normal. In
June 1970 a severe attack of abdominal pain
occurred. The serum amylase value was
880u/100 ml. This attack lasted about 10 days.
She was not hospitalized but was given De-
merol and Phenergan parenterally, with some
relief. The next attack occurred in August
1970. This was of gradual onset, but the pain
increased in intensity, with definite postpran-
dial aggravation. Pain was also worsened by
deep inhalation. The pain again was located in
the epigastric area, and was transmitted to the
back with deep inhalation. In early September
1970, the girl was hospitalized at a local hospi-
tal because of another severe attack of pain. At
that time she was afebrile, but had an elevated
serum amylase value. She was treated with
nasogastric suction and anticholinergics. The
hospital course was complicated by a bout of
upper-GI hemorrhage of moderate intensity
and by transient ascites. Serum calcium level
was 4.2 mEq/L, and the patient complained of a
"soapy taste” in her mouth. She gradually re-
covered and was dismissed from the hospital on
September 16 on a regimen including Don-
natal. Although improved, she was not com-
pletely free of pain and had lost 14 or 15
pounds. In October, November, and December
1970, attacks of abdominal pain occurred more
frequently and the patient was forced to miss a
considerable amount of school. In December
1970 there was also transmission of pain
around to the left hemithorax and towards the
back.

During the past three months, her stools
have become loose, frothy, malodorous, and dif-
ficult to flush. Postprandial pain became quite
common, as did nocturnal pain. Further, pain
was also transmitted more frequently to the
left shoulder. Pain was best relieved by leaning
forward over an object (pillow). Pentazocine
(Talwin) was prescribed by her local physician,
but it provided little relief. Also, a brief trial of
propantheline was not helpful in relieving her
pain. There is a strong family history of pan-
creatitis, which will be discussed later. The
rest of her medical and social history is non-
contributory. Since no improvement in the

154

patient’s condition could be achieved, she was
referred to the pediatric gastroenterology ser-
vice at Children’s Memorial Hospital in De-
cember 1970.

On examination, the temperature, pulse,
and respirations were normal. Examination of
the head, ears, eyes, nose, and throat showed
them to be normal, as were the heart and chest.
Examination of the abdomen revealed normal
bowel sounds, but there was diffuse tenderness
to pressure, without localization. The liver
could be palpated at the costal margin. There
was no splenomegaly, or palpable masses. The
genito-urinary system was normal. Neuro-
logical findings were also normal. Laboratory
data were as follows: Serum amylase values
were always elevated and in the range between
1,100 and 1,300 units/100 ml (normal, 60 to
160 units/100 ml). A 24-hour urine amylase
value was 6,460 units/100 ml (normal, 38 to
263 unit/100 ml). Serum calcium level was 5.4
mEq/L and alkaline phosphatase was 17
King- Armstrong units; serum glutamic ox-
aloacetic transaminase was 46 Reitland-
Franklin (RF) units (normal, 6 to 40 RF units);
bilirubin was normal; total serum protein was
5.8 gm/100 ml, with an albumin of 3.1 gm/100
ml. A fasting blood sugar was 55 mg/100 ml,
and an oral glucose tolerance test was normal.

Are there any questions about the history?
The x-ray films, including an intravenous
cholangiogram, upper GI series, barium
enema, and liver scan, will be discussed later
by the radiologist.

Doctor Riley: Doctor Poley, do you want to
emphasize any features of the history at this
point?

Doctor Poley: I would like to emphasize one
point. Whereas her abdominal pain had been
sporadic, occurring perhaps once or twice a
year at most, it became rather continuous and
more severe during the past three months. Ac-
tually, abdominal pain was one of the most
persistent symptoms.

Doctor Riley: Doctor Altman will discuss the
x-rays now.

Doctor Altman: Several examinations were
done. The patient had a normal chest x-ray.
The intravenous cholangiogram was a beauti-
ful example of a normal study. The gallbladder
opacity, the cystic duct, the hepatic ducts, and
the common bile duct were of normal caliber
and there was a normal spill of dye into the
duodenum, which rules out any obstruction of

Oklahoma State Medical Association

the biliary tract. On barium enema, the trans-
verse colon was in normal position and there
were no abnormalities. The oblique view of the
upper gastrointestinal tract (Fig 1) shows that
the stomach is slightly displaced anteriorly
and towards the left, and one gets the im-
pression that it is "draping” around a lesion
which lies posterior to the stomach. The pro-
ximal small bowel shows a normal pattern.
Spot films obtained at the time of the upper
gastrointestinal series show a normal
esophagus and gastroesophageal junction and,
on the antral side of the greater curvature, no
evidence of a pressure defect. The sweep of the
duodenum is normal in configuration and
mucosal pattern, without evidence of a lesion
in the region of the head of the pancreas. A
frontal examination by spot films again
showed a slight displacement of the stomach to
the left, apparently draping around a lesion
causing a pressure defect on the lesser curva-
ture. A liver scan outlined the uptake of the
radioactive compound in the liver and thereby
outlined the entire liver parenchyma. By
superimposing the scan onto plain films, one
can now be certain that the lesion displacing
the stomach is not liver. Rather, this lesion is
compressing the posterior and medial aspects
of the stomach and could originate from the
tail of the pancreas. In summary, I think there
is an extrahepatic, retrogastric mass which is
in the location of the tail of the pancreas.

Doctor Poley: We would like to introduce you
to the patient now. D.A.B. and Mrs. B. have
kindly agreed to come here, and please feel free
to ask questions. I have talked with D.A.B. this
morning and she was quite distressed about
losing her pants, which was due to weight loss.
Are there any questions for D.A. or Mrs. B.?
D.A., tell us briefly which region of your
tummy was most painful.

D.A.B.: Well, most of it was mostly to my left
side (epigastric area), and it goes into my back
and up to my left shoulder.

Doctor Poley: The pain in the left shoulder —
is that something new or have you had it for
some time?

D.A.B.: Some time.

Doctor Poley: For how long?

D.A.B.: About a month or two.

Doctor Wenzl: Is there a position she can get
into that gives her relief?

D.A.B.: When I bend forward, it helps, just so
I lean forward.

Doctor Poley: How did you do that the other
day when I saw you in your room?

D.A.B.: I put a pillow in front of my tummy
and bent over.

Doctor Poley: She found out that by stooping
over, by leaning forward, she could relieve her
abdominal pain. This is a very characteristic
position assumed by patients with pancreatic
type of pain, or pain that emanates from the
retroperitoneal area. She was sitting in her bed
with her legs crossed. She had a couple of pil-
lows propped in front of her and she was lean-
ing over these pillows. I wish that all of you
could have seen it. It is important when taking
a history to ask about factors or positions
which relieve pain. Any further questions?

Doctor Riley: Did the pain occur frequently
at night?

Mrs. B.: That is usually when it would occur.
She would feel pretty well when she was going
to school, but at night, either about the time
she went to bed or in the early morning hours,
she would wake up. During several weeks, she
awakened at about 2:00 AM with severe pain
and usually she would assume the position de-
scribed, but she would always need additional
medication for pain. She has taken several
drugs for pain.

Doctor Poley: Thank you.

A Physician: I want to know if the patient
had the mumps.

Mrs. B.: I don’t remember. Probably not.

A Physician: Is there history of abdominal
injury or trauma preceding the onset of this?

Doctor Poley: We could not elicit such his-
tory.

(Patient leaves.)

Doctor Poley: As Doctor Riley has men-
tioned, this patient has a rare and fascinating
problem: chronic, hereditary, familial pan-
creatitis. We believe that history and findings
are characteristic enough to suspect a pancrea-
tic pseudocyst: persistent abdominal pain, per-
sistent elevation of serum amylase, and the
retrogastric mass are compatible with such a
diagnosis, although only one out of ten patients
with hereditary pancreatitis develops a
pseudocyst.1 The first epidiascopic projection
shows the genealogical tree. (Fig 2) All indi-
viduals characterized by a cross have verified
pancreatitis. On the mother’s side, we find sev-
ral members afflicted with pancreatitis. A
maternal aunt and uncle had pancreatitis; the

Journal / May 1975 / Volume 68

155

Pancreatitis / FREED, et al

TABLE 1: CAUSES OF RECURRENT PAN-
CREATITIS

Biliary tract disease (27%)

Alcoholism (37%)

Trauma

Hyperparathyroidism

Drugs (steroids, morphine derivatives, thiazides,
lincomycin, zinc, chemotherapeutic agents —
asporaginase)

Hereditary pancreatitis
Infectious diseases
Hyperlipemia
Idiopathic (12%-40%)

Shock organ (burns, allergies)

aunt also developed diabetes during
pregnancy. The mother has a male cousin aged
34 years with chronic pancreatitis. The mother
is related to kindred "B,” which has been re-
ported in the literature.1 The patient’s younger
sister also has pancreatitis and her 10-year-old
brother probably has the disease, but we have
not examined him. The brother has elevated
serum amylase values with relatively little
discomfort, whereas the sister has severe, re-
current attacks of abdominal pains associated
with markedly elevated serum amylase.

I would now like to outline recent ideas
about the etiology and the pathogenesis of pan-
creatitis, then discuss hereditary pancreatitis
and pancreatic pseudocysts.

Table 1 summarizes causes of pancreatitis.
Biliary tract disease and chronic alcoholism
account for most cases of chronic pancreatitis.
Trauma is a quite common cause, as are drugs
— steroids, morphine derivatives, zinc, drugs
used in cancer chemotherapy, and Lincomycin
have all been linked to the development of
pancreatitis. Then, there is the large category
of so-called idiopathic pancreatitis. In various
reported series this category accounts for any-
where from 12% to 40% of all acute and chronic
pancreatitis. Then, there is hereditary pan-
creatitis and pancreatitis due to hyperlipemia.
Pancreatitis also occurs in the wake of burns:
the pancreas could be viewed as a shock organ.
It is unsettled whether allergic manifestations
could be responsible for pancreatitis. The func-
tional and clinical Marseilles classification of
pancreatitis is as follows: (1) acute pan-
creatitis, acute relapsing pancreatitis; and (2)
chronic pancreatitis and chronic relapsing
pancreatitis. The obvious difference between
(1) and (2) is that persistent disease and prog-

156

Figure 1. Oblique view of upper gastrointestinal
tract.

ressive damage are sequels only of chronic
pancreatitis.

Not much is known regarding the
pathogenesis of pancreatitis, and many
theories are still controversial. Let me briefly
summarize some recent thoughts.2 The best
hypothesis for the pathogenesis of pancreatitis
is one which is compatible with known etiolog-
ical factors, such as biliary tract disease or al-
coholism, and which would account also for the
idiopathic cases and the other rare but well-
recognized entities of pancreatitis. At the same
time, such a hypothesis should be able to ex-
plain the development of acute and chronic
pancreatitis. A reasonable pathogenetic prin-
ciple in acute pancreatitis is that of autodiges-
tion, and chronic destruction of the organ in
chronic pancreatitis.

Now, let us briefly review the possible role of
pancreatic enzymes in pancreatitis, as studied
in the experimental animal. First, consider the
effect of proteolytic enzymes on pancreatic tis-
sue. Trypsin injected in moderate concentra-
tions into the pancreatic ducts of experimental
animals caused both edema and hemorrhage,
which were due to vascular changes. However,
necrosis rarely was present. Such a pattern of

Oklahoma State Medical Association

D.A.B. HEREDITARY PANCREATITIS
© CONFIRMED PANCREATITIS

Figure 2. Genealogic tree showing members af-
flicted with pancreatitis.

inflammation does not correspond to the pat-
tern of acute pancreatitis in man. Further-
more, trypsin, if present in the pancreatic tis-
sue, is rapidly inactivated. Chymotrypsin had
an effect similar to that of trypsin.

Next, let us consider the role of elastase.
Elastase is an enzyme found in the pancreas
and activated by trypsin from pro-elastase.
Elastase dissolves elastic Fibers, as occur in
blood vessels. When elastase was injected into
the pancreatic duct of experimental animals, a
picture similar to that of trypsin-induced "pan-
creatitis” emerged, but conspicuous damage
was limited to blood vessels. The role of kallik-
rein has been studied, but its effect on pancrea-
tic tissue has not been fully elucidated. Trypsin
activates kallikreinogen to kallikrein, which
liberates kallidin and bradykinin. Kallidin
and bradykinin are among the most potent
vasodilators known, and upon the experimen-
tal use of kallikrein, vasodilatation increased
vascular permeability and vascular damage
occurred; leucocyte invasion was also reg-
istered, but pancreatic necrosis and hemor-
rhage were absent. In summary, then, the ex-
perimental use of proteolytic enzymes in ani-
mals produced only vascular and capillary
changes leading to edema and hemorrhage,
and necrosis was not predominant.

Next, let us look at the role of the lipolytic
enzymes. Again, most of the experimental data
were derived from animal studies. Lipase pro-
duced changes similar to those seen in chronic
pancreatitis of man — there was fat necrosis,
which was particularly augmented in the pres-
ence of "activators” such as bile acids. Phos-
pholipase also has been studied extensively.
Phospholipase has long been known as the

main catalyst of animal poisons. It is a diges-
tive enzyme secreted by the human pancreas
and normally is found in large concentrations
there. Phospholipase acts on phospholipids by
splitting off one fatty acid, resulting in the
production of lysophospholipids. These com-
pounds exhibit very strong cytotoxicity and
hemolysis. Lysophospholipids also can be in-
corporated into enzymes and membranes, al-
tering structure and function of the latter. In
relation to the postulated role of biliary reflux
in the pathogenesis of pancreatitis, it is of in-
terest that there are relatively large amounts
of phospholipids in bile. Further, bile acids cer-
tainly could serve as catalysts or activators of
lipase as well as of phospholipase. It has also
been postulated that trypsin may activate
pro-phospholipase, and phospholipase A has
been found in increased concentrations in the
serum of patients with acute pancreatitis.
Other pathogenetic mechanisms have to be
considered which promote tissue damage: bac-
terial toxins or the effects of viruses on mem-
branes.

Figure 3 briefly summarizes the interaction
of enzymes in the pathogenesis of pancreatitis.
Trypsin activates elastase and phospholipase
A, liberating lysophospholipids. Trypsin has to
be activated from trypsinogen, and it is not
clear how this occurs in the pancreas. Refluxed
duodenal contents containing enterokinase
could activate trypsin, but this has not been
demonstrated. Furthermore, trypsin is de-
stroyed rapidly in tissue, so the presence of a
not-yet-identified trypsin stabilizer has to be
considered. It is most likely that the combined
effects of proteolytic, lipolytic enzymes and
vasoactive substances bring about changes
seen in acute and chronic pancreatitis, but the
exact sequence of events is still unknown.

Hereditary pancreatitis was first described

?Trypsin "stabilizer”

TRYPSIN

Elastase

Enterokinase

\> Kallikreinogen — Kallikrein

Phospholipase A

(Lyso Phospholipids)
/i\

Bile Acids

Lipase

Figure 3. Interaction of enzymes in pathogenesis
of pancreatitis.

Journal / May 1975 / Volume 68

157

Pancreatitis / FREED, et al

by Comfort and Steinberg3 in 1952. Hereditary
pancreatitis has been identified in the United
States, France, Ireland, New Zealand, and the
Netherlands. The definition by Gross4 is sim-
ple and concise: inflammation of the pancreas
which is recurrent from early childhood.
Hereditary pancreatitis is transmitted as an
autosomal dominant trait with some variabil-
ity in expression and in penetrance, and there
is an unusual prevalence among blood-related
groups of persons. At the Mayo Clinic, where
most of the cases from the United States have
been studied, six certain kindreds and 21 pos-
sible kindreds have been identified, and about
one to three new kindreds are seen each year.
We have reports from 22 definite or suspected
kindreds from other countries. The nature of
the hereditary, predisposing defect is as yet
undiscovered. There is no related abnormality
recognized as common to all cases of hereditary
pancreatitis. Abnormalities of the major pan-
creatic ducts have been described and impli-
cated in the etiology and pathogenesis, but
further studies are required to settle this issue.
Aminoaciduria, with particular reference to
lysine, cystine, and orginine, has been de-
scribed in some patients with hereditary pan-
creatitis, but it occurs also in patients with
non-hereditary pancreatitis. Pancreatic cal-
cifications occur in about 40% of patients. They
are found mostly in the greater pancreatic
ducts. Diabetes and/or exocrine pancreatic in-
sufficiency is found in 20% to 25% of involved
persons.4

Most patients with hereditary pancreatitis
can be managed medically. Surgical interven-
tion is necessary when complications ensue.
The prognosis of hereditary pancreatitis gen-
erally is good. Carcinoma of the pancreas has
been reported in older persons, but there is
probably no genetic relationship to hereditary
pancreatitis. One of the outstanding findings
in hereditary pancreatitis is the absence of
significant biliary tract disease and al-
coholism.

Pancreatic pseudocysts are an unusual com-
plication. In one study, pseudocysts were rec-
ognized in from 2 to 12 patients per 100,000
hospital admissions.5 A pseudocyst may be de-
fined as the collection of pancreatic juice con-
fined by a capsule of fibers and granulation
tissue devoid of an epithelial lining. A true cyst

158

always has an epithelial lining. Etiologically,
most often there is preceding pancreatitis due
either to alcoholism or trauma. Pseudocysts
occur in idiopathic as well as in hereditary
pancreatitis. A pancreatic pseudocyst has been
recognized in about 10% of individuals v/ith
hereditary pancreatitis.1

The symptomatology of a pseudocyst de-
serves attention: the most common and persis-
tent symptom is abdominal pain. This pain is
felt usually in the upper part of the abdomen
on the left more often than on the right; pain in
the left hypochondrium may be transmitted
around the throat to the back, directly to the
back, and to the left shoulder more commonly
than to the right shoulder. Transmission of
pain to the lower abdominal quadrants has
also been reported. Other outstanding symp-
toms are nausea, vomiting, weight loss, and
diarrhea, which could be due to the exocrine
pancreatic insufficiency. A palpable mass,
present in 45% to 75% of patients, usually is
felt in the upper part of the abdomen, on the
left more frequently than on the right.6 Ten-
derness is present in three out of four patients,
but fever, jaundice, and ascites are uncommon.
A very common laboratory finding is the per-
sistence of an elevated serum amylase value,
which occurs in over 50% of cases. Diabetes is
present in about 20% to 25% of patients with
pancreatic pseudocyst, but glycosuria and
hyperglycemia were found in 50% of one series
of 42 patients.7

One of the most important tools for the iden-
tification of pancreatic pseudocysts is the
radiological examination of the upper intesti-
nal tract. In 86% of individuals with a pancrea-
tic pseudocyst, a displacement of the stomach,
mostly anteriorly, was noted, but displacement
posteriorly can also occur, and there may be
widening of the duodenal loop. Frequently, a
left pleural effusion is present, and there may
be identifiable calcifications within the pan-
creas. Sometimes a pseudocyst can displace the
colon inferiorly. An angiogram, which we orig-
inally planned to do in this patient but did not
carry out because of her sensitivity to iodi-
nated dyes, would further identify the 50% of
pseudocysts which cannot be detected by any
other means.7 A pseudocyst usually is located
anterior to the body of the pancreas, but some
unusual locations, such as in the mediastinum
or in the perinephric area can occur, and confu-
sion with renal masses is then possible.8’ 9 A
pseudocyst can be complicated by infection and

Oklahoma State Medical Association

abscesses, gastrointestinal hemorrhages, and
perforations into the stomach, duodenum, or
peritoneal cavity. Duodenal obstruction may
occur. Portal venous thrombosis has been de-
scribed, as have hypersplenism, jaundice, gas-
tric ulcerations, and rarely, a colonic fistula.

In summary then, we believe that this girl
has chronic hereditary pancreatitis with a
pseudocyst most likely complicating her di-
sease. I will return this discussion to Doctor E.
I. Smith, who will discuss surgical manage-
ment.

Doctor E. I. Smith: There are two aspects I
would like to discuss. First is the increasing
importance of pancreatitis as a differential
diagnosis in abdominal pain, and second, the
procedures which are available for the treat-
ment of chronic pancreatitis or pancreatic
pseudocysts.

Pancreatitis is an important cause of both
acute and chronic abdominal pain in childhood.
When reviewing the published cases of
hereditary pancreatitis, one is struck by the
frequency of previous appendectomies, as well
as the frequency with which bloody serous ab-
dominal fluid was noted at operation. The
upper abdomen cannot be explored properly
through a McBurney incision, and I suspect
that this is an important reason why pan-
creatitis is overlooked as a cause of the acute
pain. Pancreatitis can result from blunt
trauma, and I think that one must equate ab-
dominal pain with a battered child with the
possibility of pancreatitis. As in this case of
hereditary pancreatitis, the symptoms and
signs are rarely characteristic. They are non-
specific, and the physician must remember to
consider pancreatitis where there is abdominal
pain within very broad ranges of signs and
symptoms. Consideration of pancreatitis is im-
portant in certain high-risk groups of children
in whom abdominal pain is frequent, such as
patients with congenital spherocytosis, sickle
cell disease, or biliary tract disease, and pa-
tients receiving steroids or cancer chemo-
therapy.

Surgery for pancreatitis in children and for
pancreatic pseudocysts is concerned with de-
veloping good pancreatic flow into the in-
testinal tract and in overcoming any block to
the exocrine flow through the ductal system of
the pancreas. In traumatic pancreatitis it is
desirable to provide early drainage; this, I be-
lieve, will prevent the development of pseudo-
cysts. When a pseudocyst is present, surgical

Journal / May 1975 / Volume 68

treatment is indicated. Lastly, there are
indications for operation if there is pancreatic
lithiasis and particularly if there is evidence of
pancreatic ductal obstruction.

In general, the procedures are those of ex-
ternal drainage, internal drainage (either into
the stomach or into the loop of jejunum), and
pancreatic excision. With pseudocysts the ten-
dency has been to drain these internally, into
either the stomach or the jejunum. In the two
cases reported by Gerber,10 there was consid-
erable relief of symptoms by ductal drainage
into a loop of jejunum, but this has not been the
uniform experience.

The results of drainage of pseudocysts are
good, but complications are frequent. One
large series showed a recurrence rate of about
7%. 11 The Lahey Clinic statistics, 12 which are
colored perhaps by the inclusion of some neo-
plastic cysts, showed a secondary infection rate
of 8% and a fistula formation rate of 23%.

Pathologically, the difference between pan-
creatic cysts and pseudocysts is that the former
are lined by epithelium and the latter are not.
In the formation of pseudocysts, there is injury
to the ductal system and exocrine enzymes are
liberated into the tissues surrounding the duc-
tal system but within the general capsule of
the pancreas. By enzymatic action, this de-
velops into a cystic loculation which then con-
tinues to expand. What we do in this child’s
case depends on whether or not the cyst
communicates with the ductal system and
whether it will influence our approach. Some
studies suggest that there are intermittent
ductal blocks in children with this problem. In
draining the pseudocyst a drainage procedure
has been employed which may be of some value
later.

Doctor Seely: Has there been genetic
counseling of the family?

Doctor Poley: I would have to ask Mrs. B.
Her brother has been seen at the Mayo Clinic,
but I don’t know to what extent any members
of the family have had genetic counseling.

A Physician: Is hereditary pancreatitis more
predominant in females?

Doctor Poley: It is said to occur equally in
males and females.

A Physician: Have iso-antibodies against
pancreatitis been identified?

Doctor Poley: I have no recollection of this.

A Physician: Would you say that the phos-
pholipids in bile are higher or lower?

Doctor Poley: I mentioned phospholipids in

159

Pancreatitis / FREED, et al

bile because of the possibility of biliary reflux
into the pancreatic ductal system as a cause of
pancreatitis: if there is bile reflux, substrate is
available for phospholipase to liberate
lysophospholipids. ^

P. O. Box 26901, Oklahoma City, Oklahoma 73190

REFERENCES

I. Gross, J. B., Gambill, E. E. and Ulrich, J. A.: Hereditary pancreatitis.
Description of a fifth kindred and summary of clinical features. Amer. J. Med.

33:358-364, 1962. , J „

2 Creutzfeldt, W. and Schmidt, H.: Aetiology and pathogenesis of pan-
creatitis (Current Concepts). Scand. J. Gastroenterol 5, Suppl. 6, pp. 47-62,

19?3. Comfort, M. W., Steinberg, A. G.: Pedigree of a family with hereditary
chronic relapsing pancreatitis. Gastroenterology 21:54, 1952.

4. Gross, J. B. and Jones, J. D.: Hereditary pancreatitis present status.

Gastroenterology 58:956, 1970. ^ ^ - , ,

5 Becher, W. F., Pratt, H. S. and Ganji, H.: Pseudocyst of the pancreas.
Surg. Gynecol. O-stet. 127:744-747, 1968.

6. Thomford, N. R„ Jesseph, J. E.: Pseudocyst of the pancreas. A review of

50 cases. Amer. J. Surg. 118:86-94, 1969.

7. Caravati, C. M„ Ashworth, J. S. and Frederick, P.: Pancreatic pseudo-
cyst' A medical evaluation. J.A.M.A. 197:144, 1966. .

8. Gorder, J. L. and Stargardter, F. L.: Pancreatic pseudocyst stimulating
internal masses. Amer. J. Roentgernol. 107:65-68, 1969.

9. Hellebusch, A. A., Walton, K. N. and Griffen, W. 0., Jr.: Perinephric
pancreatic pseudocyst in a child. J. Urol. 102:633-634, 1969.

10. Gerber, B. C.: Hereditary pancreatitis. The role of surgical intervention.

Arch. Surg. 8 7:70-80, 1963. , . , . ,

II. Walker, L. G., Jr., Stone, H. H. and Apple, D. G.: Pseudocysts of the

pancreas. South. Med. J. 60:389-393, 1967. .

12. Warren, K. W., McDonald, W. M. and Veidenheimir, M. C.: Trends m
pancreatic surgery. Surg. Clin. No. Amer. 44:743-761, 1964.

Hawaii Calling

Over 200 Oklahoman’s have now signed up
for the OSMA sponsored tour to Hawaii for the
AMA’s Clinical Meeting.

The tour will depart Oklahoma City Novem-
ber 30 and" return December 5. The OSMA
package cost $575 - $595 for seven nights
superior room accommodations at the beautiful
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nights superior room accommodations at the
magnificent Maui Surf Hotel on the V alley Is-
land of Maui. It includes roundtrip jet economy
airfare from Oklahoma City to Honolulu via
Braniff 747 jet and the inter-island airfare.

A $75 per person deposit is required. If inter-
ested, please contact the OSMA immediately,
at 601 N. W. Expressway, Oklahoma City,
Oklahoma 73118. D

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brand of

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megacolon, hiatal hernia associated wit
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Address medical inquiries to: G. D. Searle & C1
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SEARLE

160

Oklahoma State Medical Association

Hypertension in Oklahoma County

S. S. SANBAR, MD, PhD

Results of a limited survey for hypertension
emphasize the need to find, follow-up and
treat victims in order to reduce morbidity

and mortality.

In a 1974 monograph by Doctor Norman M.
Kaplan1 entitled: "Your Blood Pressure: The
Most Deadly High — A Physician’s Guide to
Controlling Your Hypertension,” the following
is most of the Introduction, which is very ap-
propriate to our study:

30.000. 000 Americans have hyperten-
sion or high blood pressure.

24.000. 000 Americans do not have their
hypertension under control. Unless their
hypertension is brought under control,
they will die 20 years before they should.

On the way to their premature death,
they will have suffered twice as many
heart attacks and four times as many
strokes as those whose blood pressures
are normal.

15.000. 000 Americans don’t even know

This Study was supported by the HIGH BLOOD PRESSURE, HYPER-
LIPIDEMIA & CARDIOVASCULAR CLINIC, S. S. SANBAR, MD, PhD, Inc.,
1211 North Shartel, Oklahoma City, Okla. 73103
Volunteers who conducted the Hypertension Detection Drive: S. S. (Sam)
Sanbar, Carolyn Thompson, Eleesa Batdorf, Chantal Sanbar and Jack C. Bol-
ing, Sr.

they have hypertension. Many will find
out only after they have suffered a heart
attack or stroke.

Hypertension plays a major role in
*heart failure
*heart attacks
*kidney damage
* strokes

*rupture of major blood vessels
*hardening of the arteries
That’s the bad news. Now the good.
*Hypertension can be diagnosed easily
without pain and at little expense.

*Hypertension can be controlled,
though this takes some trouble and ex-
pense.

*When brought under control, hyper-
tension no longer causes premature death
or an increased number of heart attacks,
strokes, and other vascular diseases.

The challenge is now clear. We can pro-
long life and prevent disease in a large
number of people if we can only recognize
and control their hypertension. . . .

The purpose of this article is to depict the
blood pressures determined during a hyperten-
sion detection drive conducted among Okla-
homa County adults, including the employees
of the Cities of Oklahoma City and Midwest
City, four businesses, two church groups and
members of a PTA Convention, during the end
of 1973 and the beginning of 1974.

SOURCES OF SUBJECTS AND TECHNIQUE
OF BLOOD PRESSURE RECORDING

Table I lists the locations where blood pres-

Journal / May 1975 / Volume 68

165

TABLE I — Systolic Blood Pressure Recordings

Systolic Blood Pressure (mm. of Hg.)

Total No. 140 or Below 145 to 155 160 or Above

LOCATION of Personnel

Tested Number and Percent of Total

1. AMC Discount Store 192

2. St. Patrick Church 199

3. Crown Heights United Methodist Church 87

4. PTA Convention (1973) 258

5. Robberson Steel Co. 257

6. Liberty Bank 432

7. City Employees of Midwest City 245

8. Employees of City of Oklahoma City:

a) The City 248

b) Police Department 222

c) Zoo 113

d) Water Company 133

e) Sanitary Department 443

f) Airport 104

9. Honeywell Employees:

a) N.W. Expressway Branch 497

b) S. Portland 406

c) Building No. 5 526

d) Building No. 1 385

148 (77.1)

37 (19.3)

7 (3.6)

153 (76.8)

31 (15.6)

15 (7.6)

65 (74.7)

15 (17.2)

7 (8.04)

219 (84.8)

20 ( 8.7)

19 (7.7)

194 (75.4)

47 (18.2)

16 (6.2)

340 (78.7)

72 (16.6)

20 (5.2)

164 (67.0)

60 (24.5)

21 (8.5)

200 (80.6)

39 (15.7)

9 (3.7)

171 (77.0)

40 (18.0)

11 (5.0)

79 (70.0)

28 (24.7)

6 (5.3)

88 (66.1)

28 (21.0)

17 (12.9)

267 (60.2)

113 (22.6)

73 (14.2)

80 (76.9)

20 (19.2)

4 (3.9)

401 (80.7)

87 (17.5)

9 (1.8)

335 (82.5)

47 (11.6)

24 (5.9)

463 (88.0)

48 ( 9.1)

15 (2.9)

305 (79.2)

62 (16.1)

18 (4.7)

All Above Locations 4,747 3,672 (77.6) 794 (16.7) 281 (5.7)

sure recordings were made. A total of seven-
teen locations comprised the sites. The first
seven sites are as indicated, while the em-
ployees of the City of Oklahoma City were at
six locations, and the Honeywell Employees
were at four different locations.

Table I lists also the numbers of personnel
tested at each site. All the personnel tested
were adults between 18 and 65 years of age.
The total number of personnel tested at all se-
venteen sites was 4,747.

Sitting blood pressure was recorded in the
right arm, using two Model 1905 London Pres-
surometers S/N 139. These instruments de-
termine blood pressure electronically and
automatically with a direct blood pressure
read-out. At least one blood pressure was ob-
tained. In hypertensive patients, two re-
cordings were made, and occasionally blood
pressure in the left arm was recorded for con-
firmation.

RESULTS

Tables I and II show respectively the systolic
and diastolic blood pressure. The blood pres-
sures were further subdivided into three sub-
groups:

166

a) Normal blood pressure: Systolic 140 mm
of Hg or below, Diastolic 90 mm of Hg or
below,

b) Borderline Hypertensives: Systolic 145 to
155 mm of Hg, Diastolic 95 to 100 mm of

Hg,

c) Hypertensives: Systolic 160 mm of Hg or
above, Diastolic 105 mm of Hg or above,

Normal systolic blood pressures were ob-
tained in 3,672 (77.6%), while 794 (16.4%) had
borderline hypertension and 281 (5.7%) had
hypertension. Thus, 22.2% of all subjects tested
had systolic blood pressures above 140 mm of
Hg. There were some variations in percent of

S. S. Sanbar received his medical degree
from the American University of Beirut in 1960
and his PhD degree from the University of
Oklahoma in 1963. He is Clinical Assistant
Professor at the University of Oklahoma Health
Sciences Center. Among his medical affiliations
are the American Heart Association, the Ameri-
can Federation for Clinical Research, the
American Diabetes Association, the Cardiac
Society and the Osier Society.

Oklahoma State Medical Association

TABLE II — Diastolic Blood Pressure Recordings

Diastolic Blood Pressure (mm. of Hg.)

Total No. 90 or Below 95 to 100 105 or Above

LOCATION of Personnel

Tested Number (and Percent of Total)

AMC Discount Store

192

167 (87.0)

19 (9.9)

6 (3.1)

St. Patrick Church

199

184 (92.4)

13 (6.6)

2 (1.0)

Crown Heights United Methodist Church 87

82 (94.2)

4 (4.6)

1 (1.2)

PTA Convention (1973)

258

233 (90.3)

16 (6.2)

9 (3.5)

Robberson Steel Co.

257

248 (96.4)

6 (2.4)

3 (1.2)

Liberty Bank

432

402 (93.0)

18 (4.2)

12 (2.8)

City Employees of Midwest City

245

229 (93.5)

11 (4.4)

5 (2.1)

Employees of City of Oklahoma City:
a) The City

248

241 (97.2)

4 (1.6)

3 (1.2)

b) Police Department

222

208 (93.7)

10 (4.5)

4 (1.8)

c) Zoo

113

108 (95.6)

4 (3.6)

1 (0.8)

d) Water Company

133

121 (90.9)

9 (6.8)

3 (2.3)

e) Sanitary Department

443

393 (88.7)

35 (7.9)

15 (3.4)

f) Airport

104

99 (95.3)

4 (3.8)

1 (0.9)

Honeywell Employees:
a) N.W. Expressway Branch

497

476 (95.7)

17 (3.4)

4 (0.9)

b) S. Portland

406

387 (95.3)

13 (3.2)

6 (1.5)

c) Building No. 5

526

510 (96.9)

10 (1.9)

6 (1.2)

d) Building No. 1

385

362 (94.0)

17 (4.4)

6 (1.6)

All above locations

4,747

4,450 (93.7)

210 (4.4)

87 (1.9)

systolic hypertensives in the 17 locations
tested, as noted in Table I, with the Water
Company, Sanitary Department, the Zoo, and
City of Midwest City employees leading in the
incidence of elevated blood pressures.

In contrast with systolic blood pressures, the
diastolic blood pressures were normal in 4,450
(93.7%) of subjects tested. There were 210
(4.4%) with borderline diastolic hypertension
and only 87 (1.9%) with diastolic hypertension.
The AMC Store and the Sanitary Department
had the highest percentage of elevated dias-
tolic blood pressures.

DISCUSSION

It is hoped that the year 1974 will be re-
corded in the history of American medicine as
the year of the nationwide campaign against
hypertension. Indeed, May, 1974, was desig-
nated as "National High Blood Pressure
Month.” The American Medical Associaton,
the American Heart Association, the National
Medical Association, the Citizens for Treat-
ment of High Blood Pressure, and the US De-
partment of Health, Education and Welfare
sponsored and/or endorsed the campaign
against hypertension.

The data presented in this article substan-
tiate the existence of a significant group of
hypertensive subjects in Oklahoma County
(despite the fact that some of those subjects
tested were on medications for hypertension).
This study compares favorably with numerous
other studies.1'6 No attempt was made to sort
the subjects tested according to weight, height,
sex, race, age or what have you. The point of
the study is to draw attention to the prevalence
of blood pressure elevation in adults in a vari-
ety of settings, from the church-goer, con-
ventioneer, hard-hat employees to desk job
holders and city employees. "The challenge is
now clear,” as Doctor N. Kaplan put it. We
should recognize hypertension and more im-
portantly, effectively control it to prolong life.
We have the means to help hypertensive pa-
tients, and it behooves us as physicians to join
in the all out effort to control hypertension and
minimize its complications.

SUMMARY

The prevalence of elevated systolic and dias-
tolic blood pressures was 22.2% and 6.3% re-
spectively in 4,747 subjects tested, including
employees of businesses, the Cities of Okla-

Journal / May 1975 / Volume 68

167

Hypertension / SANBAR

homa City and Midwest City, and church and
convention-goers. D

1211 North Shartel, Oklahoma City, Oklahoma
73103

REFERENCES

1. Kaplan, N. M.: Your Blood Pressure: The Most Deadly High. MEDCOM
PRESS, N.Y., N.Y., 1974, p. 11-12.

2. U.S. Department of Health, Education and Welfare: Blood Pressure of
Adults by Race and Area, United States, 1960-1962. National Health Survey,
National Center for Health Statistics, Series 11: Numbers 4 and 5, 1962, and
Number 13, 1966.

3. Schoenberger, J. A., Stamler, J., Shekelle, R. B., and Shekelle, S.: Current
Status of Hypertension Control in an Industrial Population. JAMA 222: 559,

1972.

4. Stamler, J.: High Blood Pressure in the United States — An Overview of
the Problem and the Challenge. In: Proceedings of the National Conference on
High Blood Pressure Education. National Heart and Lung Institute. US De-
partment of Health, Education and Welfare publication number (NIH) 73-486,

1973, p. 11.

5. Hypertension Manual: J. H. Laragh, Ed., Yorke Medical Books, Dun-
Donnelley Publishing Corp., N.Y., 1973, p-44.

6. Clinical Hypertension: Kaplan, N. M., MEDCOM PRESS, N.Y., N.Y.,
1973, p. 1.

The American Association

for

CLINICAL IMMUNOLOGY
and ALLERGY

The Annual Meeting of The American Association for Clinical
Immunology and Allergy will be held at the Riviera Hotel, Palm
Springs, California, October 15th- 16th, 1975.

Please direct all inquiries to Staff Administrator, Howard Silber,
AACIA, P.O. Box 912, DTS, Omaha, Nebraska 402 558-5345.

168

Oklahoma State Medical Association

AMPICILLIN-RESISTANT
HEMOPHILUS INFLUENZAE

Ampicillin-resistant strains of H. influenzae
have been documented in Oklahoma. The fol-
lowing brief commentary discusses the effect of
this occurrence on recommended treatment of
bacterial meningitis.

In children more than two months of age
Hemophilus influenzae type B is the most fre-
quent cause of bacterial meningitis. Until re-
cently, virtually every authority has recom-
mended large doses of ampicillin for initial
treatment of meningitis in children before the
results of laboratory tests are known. In past
months there have been many reports of
meningitis in children caused by ampicillin-
resistant H. influenzae. Ampicillin-resistant
organisms still cause only a small fraction of
cases of bacterial meningitis. Clinical reports
indicate, however, that inadequate treatment
of those few patients who do have meningitis
with an ampicillin-resistant strain, even for

News From
e Oklahoma State
Department of
Health

one or two days until laboratory reports are
available, may result in death or severe
neurological damage.

In a recent statement published in Pediat-
rics (55: 145, January 1975), the American
Academy of Pediatrics recommends that "in
areas where resistant strains have been recog-
nized when H. influenzae type B is suspect as
the pathogen, initial treatment of bacterial
meningitis should include penicillin G or am-
picillin, plus chloramphenicol in a dosage of
100 mg/kg/ day.” □

REFERENCE

The Medical Letter, Vol. 17, No. 4, February 4, 1975.

COMMUNICABLE DISEASES IN OKLAHOMA FOR MARCH, 1975

DISEASE

March

1975

March

1974

February

1975

Total To Date
1975 1974

Amebiasis

Brucellosis

—

Chickenpox

205

279

185

515

414

Encephalitis, Infectious

—

Gonorrhea (Use Form ODH-228)

1046

1032

921

2965

2400

Hepatitis, A, B, Unspecified

100

256

308

Leptospirosis

—

Malaria

—

Meningococcal Infections

Meningitis, Aseptic

Mumps

134

208

Rabies in Animals

Rheumatic Fever

—

Rocky Mountain Spotted Fever

—

Rubella

Rubella, Congenital Syndrome

—

Rubeola

Salmonellosis

Shigellosis

139

Syphilis, Infectious

(Use Form ODH-228)
Tetanus

Tuberculosis, New Active

Tularemia

—

Typhoid Fever

—

Whooping Cough

For Consultation Call: (405) 271-4060

Journal / May 1975 / Volume 68

169

Medical Summit ’75
Was “Biggest and Best”

Medical Summit ’75 was cited as the "best”
meeting they had ever attended by numerous
physicians during the four-day meeting. The
combined annual meeting of the Oklahoma
State Medical Association, Oklahoma
Academy of Family Physicians, and Oklahoma
City Clinical Society attracted over 2,500 per-
sons.

Held April 23rd-26th in Oklahoma City’s
Lincoln Plaza, Oklahoma Medical Summit ’75
set an attendance record for physicians, when
it registered 846 MB’s. In addition, 95 medical
students and 818 members of allied health
groups registered.

During the four-day meeting Oklahoma
physicians could choose from over 70 hours of
medical and scientific lectures. In addition,
they could view nearly 100 scientific, techni-
cal, pharmaceutical and business exhibits.

Almost all of the social functions were "sell-
out” crowds. In addition, the Superstar Lun-
cheons attracted nearly 250 persons each, with
the exception of the Saturday luncheon which
attracted over 350 persons. On Saturday, Gov-
ernor David Boren was the guest Luncheon
Speaker along with Joe Nelson, MD, AMA
Trustee from Weatherford, Texas.

Plans have already begun for Oklahoma
Medical Summit ’76! □

Utilization Review Regulations
Incur Delegates’ Rath

The new regulations regarding Utilization
Review that were published November 29th,
1974, by the Secretary of Health, Education,
and Welfare were described as "blatant at-
tempts to ration health care and to close
America’s rural hospitals” by numerous
speakers during debate on a resolution not to
participate in such reviews.

Three resolutions calling for non-
participation in the new regulations were pre-

170

sented to the OSMA House of Delegates for its
consideration. The resolutions were thor-
oughly discussed by a reference committee of
the house on Thursday, April 24th. Following
numerous speakers, the reference committee
recommended that the house disregard the
three resolutions, and consider a substitute
resolution in their place.

During debate before the full House of Dele-
gates on Friday, April 25th, the substitute
resolution was amended, and finally adopted,
as follows: [

UTILIZATION REVIEW POSITION

Whereas, the published regulations appear-
ing in the Federal Register on November 29th,
1974 implementing Utilization Review are in-
consistent with good patient care, infringe on
the doctor-patient relationship, threaten the
confidentiality of that relationship, constitutes
unsolicitated and therefore unethical consulta-
tion, promulgate the deterioration of quality
medical care, pose the potential threat of clos-
ing many hospitals and threaten our patients
with possible loss of hospital privileges and fi-
nancial assistance, and

Whereas, Peer Review and Utilization Re-
view has been traditionally performed by the
profession to assure quality medical care, not
cost control, and is best handled at the local
level so that it can take into consideration local
problems, and

Whereas, any nationwide method of Utiliza-
tion Review must necessarily ignore such local
problems and cannot be accurately varied into
size of hospital facility of medical staff, and
Whereas, any such national scheme will re-
sult only in a rationing of health care services
to patients, therefore be it

Resolved, that the physicians of the State of
Oklahoma vigorously support the American
Medical Association’s lawsuit against these
onerous regulations and, therefore be it

Resolved, that the physicians of the State of
Oklahoma will continue Utilization Review
and Peer Review on an individual hospital
basis, and will not participate in Utilization
Review as outlined in the above cited regula-
tions, and

Whereas, the Oklahoma State Medical As-
sociation recognizes that this stance will re-
quire a public relations campaign to inform the
general public as to the necessity for this posi-
tion, now therefore be it

Resolved, that the House of Delegates of the

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Oklahoma State Medical Association

Oklahoma State Medical Association authorize
the OSMA Board of Trustees to institute a vol-
untary assessment to establish an adequate
public relations campaign budget should this
become necessary, and therefore be it further

Resolved, that the Oklahoma State Medical
Association seek the broadest possible base of
support in such a campaign by inviting the
cooperation of physicians in other medical as-
sociations throughout the United States, and
be it further

Resolved, that the Oklahoma Congressional
Delegation be apprised of the content of this
resolution.

Immediately after the House of Delegates
adjourned on Friday, a special meeting of the
OSMA Board of Trustees was called to appoint
an Ad Hoc Committee to supervise the cam-
paign called for in the resolution. The commit-
tee immediately began by contacting a profes-
sional public relations consultant, Mr. Chuck
Schnake of Tulsa, and asked him to prepare a
budget for presentation to the OSMA Board of
Trustees at a later date. In addition, the com-
mittee worked out a tentative plan of action.

One of the first actions of the committee was
to authorize the OSMA Staff to notify all other
state medical associations of the position taken
by the OSMA and to forward to them a copy of
the OSMA’s resolution. In addition, all mem-
bers of the association were notified of the ac-
tion and sent a copy of the resolution.

In a letter to the other state medical associa-
tions, Arnold G. Nelson, MD, OSMA President,
stated, "Oklahoma physicians have taken a
firm position in opposition to the Utilization
Review process mandated by Secretary Wein-
berger in the Federal Register, November
29th, 1974. By an overwhelming vote of 141-2
our House of Delegates adopted the attached
resolution.

Doctor Nelson then went on to state that this
position was taken after considerable delibera-
tion and then pointed out that 42 rural hospi-
tals in Oklahoma could possibly close as a re-
sult of implementing the regulations. He
stated, "In our larger institutions the result
would be the denial of benefits to many of our
patients.

"The inflexibility of Secretary Weinberger’s
position about modifying the regulations to ac-
commodate the unique characteristics of dif-
ferent geographic areas is an indication that he
neither understands nor sympathizes with
local problems. We have received considerable
help from our Governor and we are supported

in our position by the Director of the Depart-
ment of Institutions, Social and Rehabilitative
Services and by the Commissioner of our State
Department of Health.

"We sincerely urge that your association
adopt a resolution similar to the one attached.
We recognize that this is a national effort and
if we are to succeed, we will need a broad base
of support.”

The President then went on to offer to send a
representative to any annual meeting of any
state medical association to explain the Okla-
homa position.

In a letter to all members of the association
President Nelson said, "It is the intention of
your association to do everything in its power
to see that these regulations are rescinded.

"It is our intention to mount a public rela-
tions campaign that will point out that these
regulations are a blatant attempt to ration
health care under the guise of 'cost controls’
and that their implementation will result in
the closing of many of Oklahoma’s small hospi-
tals.”

In closing his letter to OSMA members, Doc-
tor Nelson asked that the physician "join with
us by not participating in the new Utilization
Review Regulations. Please understand that it
is still incumbent upon us, as physicians, to do
our own Utilization and Peer Review in indi-
vidual hospitals and to continue doing Utiliza-
tion Review under the old method.” □

SEARCH
IN COMPLETE
SILENCE

have you considered exploring the feasibil-
ity of changing your present location?

We have a discreet third party approach that
can save you time and effort. We have many
opportunities which can be explored in com-
plete confidence by calling Jack Grinovich
collect at (405) 525-5544 or by writing
Corporate Recruiters, Suite 630, 2200 Clas-
sen Boulevard, Oklahoma City, Oklahoma
73106.

Journal / May 1975 / Volume 68

171

Oklahoma Medit

Arnold G. Nelson, MD, (left) as-
sumed leadership of the state’s
largest medical group, the OSMA.
Orange M. Welborn, MD, Ada,
(center) took over the reins as
President-Elect of the state associ-
ation. William M. Leebron, MD, a
general surgeon from Elk City, be-
came Vice-President of the group.

David L. Boren, (below) Governor of the
State of Oklahoma, addresses Oklahoma
Medical Summit ’75 on Saturday afternoon,
April 26th.

Below are the Past-Presidents of the OSMA who attended the annual breakfast in
their honor. Left to right are: Stanley R. McCampbell, MD, Oklahoma City; George H.
Garrison, MD, Oklahoma City; Clinton Gallaher, MD, Shawnee; J. Hoyle Carlock, MD,
Ardmore; Jack L. Richardson, MD, Tulsa, OSMA President; Hillard Denyer, MD, Bart-
lesville; Ed Calhoon, MD, Beaver; Scott Hendren, MD, Oklahoma City and, Harlan
Thomas, MD, Tulsa.

172

Oklahoma State Medical Association

mmit

’75

Above, Rex Kenyon, MD, (right), member of AMPAC Board of Directors, is shown
congratulating Kent Braden, MD, (left) and Ed L. Calhoon, MD, Chairmen of the
Oklahoma Medical Political Action Committee for 1974-75, with an award for second
place winner in the National AMPAC campaign.

Jr, :

, - ft* •

Pictured right, Howard B.
Keith, MD, Shattuck, is shown re-
ceiving a plaque of appreciation
from Jack L. Richardson, MD,
Tulsa, President of the OSMA.
Doctor Keith’s outstanding service
on the Peer Review Committee for
seven years was acknowledged by
the OSMA House of Delegates.

Seen at the left are Thomas N.
Lynn, MD, (right), acting Dean of
the University of Oklahoma
Health Sciences Center, receiving
an AMA-ERF check for $17,648.38
from Arnold G. Nelson, MD, in-
coming President of the OSMA.

Journal / May 1975 / Volume 68

173

BEVERLY HILLS HOSPITAL
BEVERLY HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

A Private 115 bed psychiatric hospital located in Oak Cliff on 18 acres amidst natural wooded sur-
roundings. A multi-approach treatment center of neurologic and all psychiatric disorders. Treatment
modalities include Somatic Therapy, Milieu Therapy, Chemotherapy, Individual and Group Therapy,.
Transactional Analysis, Gestalt, and Behavior Modification. Complete facilities for OT-RT under the
division of trained personnel. An individually directed program based on full diagnostic evaluation and
actual performance administered by a staff skilled in special education and problems of the adoles-
cent and young adult.

PSYCHIATRY

Jackson H. Speegle, MD
John T. Holbrook, MD

Fred H. Jordan, MD
Joseph H. Lindsay, MD

PSYCHOLOGY

George R. Mount, PhD
Donald L. Whaley, PhD

Tom I. Payton, MS
Patrick R. Barnes, MS

EDUCATION DIRECTOR

William E. Nix, PhD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND RT. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211

214 331-8331

174

Oklahoma State Medical Association

Sixteen Resolutions Considered
By House of Delegates

During the Annual Meeting of the OSMA
House of Delegates, held April 23rd-26th, the
House considered 16 separate resolutions. The
annual meeting of the house was held in con-
junction with Oklahoma Medical Summit, the
combined annual meeting of the OSMA, Okla-
homa Academy of Family Physicians, and
Oklahoma City Clinical Society in Oklahoma
City’s Lincoln Plaza Hotel.

The Opening Session of the House of Dele-
gates was conducted on Wednesday afternoon,
April 23rd, the Reference Committees met on
April 24th, and the Closing Session was Friday
morning, April 25th.

The sixteen resolutions considered by the
House came from various county medical
societies and individual members of the associ-
ation.

Resolutions Nos. 2, 3 and 6 all dealt with pro-
posed amendments to the OSMA Constitution
and By-laws and whether or not American
Medical Association membership should be
mandatory in Oklahoma. A full explanation of
what happened on these three resolutions is
contained in a separate story in this issue of
The Journal dealing with the AMA dues.

Resolution No. 1 was introduced by the
Oklahoma County Medical Society and dealt
r with insurance claim forms. This resolution re-
1 solved that physicians of Oklahoma be encour-
t aged to use the AMA’s Uniform Claim Form
ie| for all accident and health insurance reports
c and that if an insurance company insisted on
s its own form, an appropriate charge could be
made by the physician for his time and incon-
venience.

In its report, the Reference Committee noted
that no member of the Oklahoma County Med-
ical Society was available to bring to the com-
mittee information on the AMA Uniform
Claim Form. Lacking this information, the
committee felt that it could not recommend
passage of the resolution. The house concurred,
and the resolution did not pass.

The house next dealt with Resolution No. 12,
submitted by the Oklahoma County Medical
Society in regard to AMA Publications. The
house adopted the following amended resolu-
tion No. 12: Resolved, that the Oklahoma State
Medical Association urge the American Medi-
cal Association to discontinue, immediately,

free distribution of all publications, except for
JAMA and items of news or organizational in-
terest, and, be it further

Resolved, that the AMA establish a sub-
scription price that will pay for its other publi-
cations, or, if such a subscription price is not
feasible, that it discontinue, immediately, the
publication of specialty journals, Prism, and all
other magazines, leaflets, and brochures not
fiscally sound.

All of the above cited resolutions were con-
sidered by Reference Committee No. I. Ref-
erence Committee No. II considered Resolutions
Nos. 7, 8, and 15.

The Reference Committee dealt with Resolu-
tions Nos. 7 and 8 jointly. Both were introduced
by the Kingfisher County Medical Society and
No. 7 dealt with "release of information to
third party carriers” while No. 8 was on "pre-
existing illnesses.” In its report the committee
stated, "Both resolutions . . . deal with insur-
ance companies and the policies they use to
underwrite the risks they insure.”

Resolution No. 7 expresses concern over the
retrospective review of patients’ medical rec-
ords after claims have been filed. Resolution
No. 8 addresses itself to the problem of the
"pre-existing illness” clause and insurance pol-
icies that result in the denial of some claims.
Testimony (before the committee) cited the
problems of patients who, after paying pre-
miums for years, find that specific illnesses are
not covered on the grounds of being "pre-
existing.” Your Reference Committee ex-
presses concern over the less than honorable
practice of some insurance companies, but we
recognize that certain information and inves-
tigations are necessary to the insurance indus-
try.

The reference committee then recommended
that both resolutions be referred to the
OSMA’s Council on Insurance with instruc-
tions that they study these problems and make
recommendations to the Board of Trustees.
This recommendation was adopted by the
House of Delegates.

Resolution No. 15, introduced by the OSMA
Medical Center Liaison Committee and the
OSMA Legislative Committee, requested that
a committee be appointed to study the admis-
sions policy of the OU College of Medicine. The
committee pointed out, ". . . it is obvious that
a great number of physicians in the state, in
addition to our political leaders and the lay

(Continued on Page 177)

Journal / May 1975 / Volume 68

175

HEALTH CARE MANAGEMENT

MASSES OF PAPERWORK AND SLOW RECEIVABLES

. these two enemies are overwhelming todays Medical
Office! How to deal with these two is the “number one
business problem” for many doctors.

HCM's system is simple, easy to learn, requires no
special equipment, is flexible, and can follow along the
lines of your present business office procedures.

For further information, contact:
Gene Highfill

Academy Computing Corporation
3535 NW 58th — Suite 102
Oklahoma City, Oklahoma 73112
405/947-7746

SPONSORED BYTHE OSMA

Washington Nationa! Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE
DISABILITY INCOME INSURANCE

Contact Association Counselors:

Jim Thaxton, Bill Howard or Rodman A. Frates

Administrators

720 NW 50th

PC Box 18593 405 842-3735 Oklahoma City 73118

176

Oklahoma State Medical Association

(Continued from Page 175)

public, do not understand the admissions pol-
icies of the OU College of Medicine. We feel
that a comprehensive study with accompany-
ing public relations and dissemination of in-
formation to the physicians of Oklahoma
would be of great benefit to the school.”

The resolution called for the creation of a
special committee to consist of two physicians
from each of Oklahoma’s six Congressional
Districts and five physicians representing the
faculty and staff of the OU College of Medicine.
This committee was to convene as often as
necessary to study the admissions policy of the
College of Medicine and to then file a full re-
port of its findings with the Executive Commit-
tee of the Oklahoma Legislative Council at
least 30 days prior to convening of the second
Session of the 35th Oklahoma Legislature.

The Reference Committee, in its report to
the house, noted that it had been informed that
a Senate joint resolution had been passed by
the Oklahoma Senate that would legislate the
composition of the Board of Admissions. The
committee had also been advised that the au-
thors of the bill had under consideration
amendments that would require membership
of the Board of Admissions to represent each of
the six Congressional Districts.

Reference Committee No. Ill considered
Resolutions Nos. 4, 5, 9, 10, 11, 13, 14 and 16.

Resolutions Nos. 5, 10 and 13 were considered
jointly. The first two were introduced by the
Kingfisher County Medical Society, and the
Oklahoma County Society introduced No. 13.
Each dealt with the new Utilization Review
Regulations being promulgated by the Secre-
tary of HEW.

The reference committee drafted a substitute
resolution to be adopted in place of the three. A
full report on the substitute resolution and the
actions that followed its adoption are included
in another article in this issue of the OSMA
Journal.

Resolution No. 4 was introduced by the
Tulsa County Medical Society and dealt with
support of Emergency Medical Services Sys-
tems. It was considered by the reference com-
mittee in conjunction with the report of the
Emergency Medical Services Committee of the
Council on Public Health of the OSMA. This
resolution resolved that the OSMA should
"support the concept of the comprehensive sys-
tem of Emergency Medical Services, and that
physicians evidence their support by participa-

Journal / May 1975 / Volume 68

tion in activities of design and development of
Emergency Medical Services Systems; and
. . . that physicians support and participate in
the training of Emergency Medical Techni-
cians and other allied health personnel in the
delivery of such services; and . . . that physi-
cians participate in the assurance of the capa-
bility of hospitals to deliver quality emergency
care; and . . . that the OSMA urge other
health professional organizations to resolve
their support for such Emergency Medical Ser-
vices Systems.”

Resolution No. 9 dealt with the "repeal of
HEW’s Professional Standards Review Or-
ganization” and was introduced by the King-
fisher County Medical Society. After consid-
eration by the Reference Committee, the com-
mittee noted that it felt this resolution was
simply a restatement of the association’s cur-
rent policy.

Resolution No. 9, as adopted, resolved that
"HEW’s Professional Standards Review Or-
ganization law be repealed and that this stand
for repeal be adopted by the Oklahoma State
Medical Association.”

Ray McIntyre, MD, representing the King-
fisher County Medical Society stated that it
was not the intention of this resolution to
withdraw the House of Delegates permission to
the Oklahoma Foundation for Peer Review to
apply for a PSRO Planning Grant. He stated
the intent of the resolution was simply to reaf-
firm the association’s position that the law
should be repealed.

The Comanche-Cotton-Tillman Counties
Medical Society introduced Resolution No. 11
dealing with "collective bargaining by the
AMA.” The resolution called for the AMA to
change its structure or constitution and add a
division "to allow its members to be rep-
resented by an effective collective bargaining
agent to deal with all organizations involved in
health care . . .”

The reference committee pointed out to the
House of Delegates that it had been informed
that the AMA had created an Office of
Negotiations that was already active. It fur-
ther stated that until such time as the new
offices’ functions were clarified and delineated,
it did not feel that the OSMA should take any
action on the subject of collective bargaining
by the AMA. The resolution was not adopted.

Two physicians from Stillwater, William
Gamier, MD, and Sidney Williams, MD, intro-

177

news

duced Resolution No. 14 on the subject of "eye-
glass prescriptions from ophthalmologists.” In
their resolution they pointed out that the Judi-
cial Council of the American Medical Associa-
tion requires physicians to furnish to their pa-
tients copies of any prescriptions for eye-
glasses, drugs, or appliances. They then went
on to point out that the peculiarities of Okla-
homa law hold ophthalmologists liable for the
"full effect” of any eyeglasses furnished in re-
sponse to a prescription.

After hearing testimony, the reference com-
mittee recommended that the section of the
Oklahoma Statute cited in the resolution was
at fault and should be changed. However, it felt
that the Judicial Council’s opinion should be
maintained in force.

Doctor Gamier personally appeared before
the House of Delegates and asked that the Ref-
erence Committee recommendation be over-
turned and that his resolution be adopted.

Following some limited debate, the House of
Delegates approved a substitute motion to the
effect that the Judicial Council’s opinion in re-
gard to the prescription for glasses be waived
until such time as the Oklahoma law is
changed.

Resolution No. 16 was introduced by Kent
Braden, MD, and dealt with many aspects of
the "physician-patient relationship.”

In its report to the House of Delegates the
Reference Committee stated, "Mr. Speaker,
your committee considered this resolution very
carefully. While the committee admired the
philosophy outlined in this resolution, the re-
solves it contains are so far reaching and en-
compass so many facets of the social, economic,
and political aspects of the practice of medicine
as to make it untenable in this form. Many of
the resolves/are being handled specifically by
the reports of the association’s various coun-
cils, committees, and other resolutions.

"Your committee wishes to specifically
commend Kent Braden, MD, for so eloquently
outlining the philosophy that we would all like
to espouse. However, an attempt to encompass
it all in one omnibus resolution simply is un-
workable.”

The Chairman of the Reference Committee
then moved that Resolution 16 not be adopted.
This motion was accepted by the House of

Delegates. □

178

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House Votes to Retain
Mandatory AMA Membership

The OSMA House of Delegates, meeting in
regular session on April 25th, voted to retain
that section of the OSMA By-laws that require
members of the state association to also belong
to the American Medical Association.

The house rejected several resolutions call-
ing for AMA membership to be voluntary. One
reference committee of the house considered a
number of resolutions on the subject when it
met on Thursday, April 24th. Following the
presentation of numerous oral arguments for
and against voluntary AMA membership, the
reference committee proposed that the three
resolutions on the subject be considered as a
single item by the delegates. The reference
committee was unable to reach a unanimous
decision as to what action should be recom-
mended to the delegates.

Following lengthy discussion on the floor of
the house, it was moved by a delegate from
Washington County that the mandatory AMA
membership be retained. The motion was sec-
onded and passed by the delegates.

The action of the House of Delegates leaves
the by-laws of the state medical association as
they are currently written: ie, in order to be a
member of the Oklahoma State Medical As-
sociation, a physician must also be a member of
his local county medical society and the
American Medical Association. □

Oklahoma State Medical Association

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance
Springfield, Mass.

For additional details and application form, please contact

Jim Thaxton

Administrator

720 N. W. 50th Telephone 405 848-7661

P.O. Box 18593 Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

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exceed $400,000.

Is this logical? Not when you can participate in the . . .

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Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION
. . . gives you individual coverage at low group rates.

. . . offers flexible waiting periods at your option.

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. . . offers optional Indemnity from $200.00 to $2,500.00 per month.

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C. L. FRATES & COMPANY, INC.

720 N.W. 50th P.O. Box 18695
OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848-7661

Journal / May 1975 / Volume 68

179

news

OSMA House Votes
Dues Increase

A $30 dues increase, to bring OSMA dues to
$150 annually, was voted by the medical
association’s House of Delegates when it met
on Friday, April 25th, during Oklahoma Medi-
cal Summit.

The Annual Report of the OSMA’s Board of
Trustees to the House of Delegates illustrated
the need for a dues increase by showing the
ever-widening areas of activity of the associa-
tion. The trustees observed to the delegates
that the association cannot operate at its past
level without experiencing a deficit. The board
then took the position that the OSMA could not
be permitted to deteriorate in any fashion, and
requested that the House of Delegates adopt a
dues increase for 1976.

The reference committee that considered the
reports of the Board of Trustees, Supplemental
Board of Trustees Report, and Secretary-
Treasurer Report, recommended that the dues
be increased by $30. This amount would pro-
duce approximately $25,000 in new income for

the next fiscal year and would generate as
much as $60,000 for the following fiscal year.
The fiscal year of the association runs from
June 1st through May 31st of the following
calendar year.

The reference committee cited to the House
of Delegates that numerous major issues were
currently confronting the association, "such as
the matter of non-participation in federalized
Utilization Review Regulations. A strong
stance against these regulations will present a
major public relations problem to the associa-
tion which cannot be sustained by any reason-
able dues increase.”

The Report of the Reference Committee then
went on to state, "your committee, therefore,
observes to the House of Delegates that major
confrontations against onerous federal regula-
tions will undoubtedly require a special
assessment in order to develop a successful re-
sponse to punitive federal actions which may
be taken against the profession.”

The new dues increase will become effective
January 1st, 1976. The association operates on
a fiscal year, but collects its dues on a calendar
year. The dues increase will be included in the
dues statements to be sent out in December of
this year. □

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180

Oklahoma State Medical Association

Death

ROBERT L. LOY, JR., MD
1914-1975

Robert L. Loy, Jr., MD, Oklahoma
City general practitioner, died April
9th, 1975. Born in El Reno, Doctor Loy
lived most of his life in Oklahoma City.

In 1947, he was graduated from the
University of Oklahoma College of
Medicine, where later he became an
Instructor in Obstetrics.

Doctor Loy served with the US Army
during World War II and was a
member of the county, state and na-
tional medical associations. □

Arkansas-Oklahoma Cancer Forum
Scheduled For September

Fort Smith, Arkansas, has again been
selected as the site of the Seventh Annual
Arkansas-Oklahoma Cancer Forum. Dates for
the one and a half-day meeting will be Sep-
tember 25th and 26th, 1975.

According to Guy Robbins, MD, Head of the
Breast Service, Memorial Hospital, New York
City, an outstanding program is being formu-
lated. Speakers from Memorial Hospital and
the Sloan Kettering Institute will highlight
the presentations. A wide variety of subjects,
including practical topics and recent innova-
tions, will fill the program.

The Sheraton Inn in Fort Smith will be
headquarters for the forum. Further details
will be announced later. □

Summit Photo Contest
Winners Announced

Six Oklahoma physicians were selected as
winners in the Oklahoma Medical Summit
Photography Contest for physicians and their
spouses.

The two judges, David Fitzgerald, a commer-
cial photographer in Oklahoma City, and
Raymond Riggs, an international amateur
salon exhibitor, unanimously selected Doctor
Harold Sleeper’s photograph of a hummingbird
as the "Best Of Show.” Both photographers
pointed out the technical difficulties involved
in making such a photograph.

First place in the color competition was won
by Fred Switzer, MD, of McAlester for his

photograph of a mountain pass. Second place in
the color competitions went to Marcel Bin-
stock, MD, of Tulsa for his photograph of
"Mountain Meadow.”

In the black and white competition, Ken
Whittington, MD, of Oklahoma City won first
place with his photograph of a boy with a
pumpkin. Second place went to Doctor Richard
Dawson of Oklahoma City for his photograph
of a girl in a car window.

Both judges insisted that an honorable men-
tion be given to the two color photographs of an
oil well fire by Doctor Bill Leebron of Elk City.
Both judges noted that from the standpoint of
interest, there probably were not two more
popular photographs in the display. □

L. H. Becker, MD, To Be Honored

The residents of Blackwell, Oklahoma, will
honor Doctor L. H. Becker at an open house on
June 1st, 1975. The event will be held in the
V.F.W. Hall in Blackwell from two to five Sun-
day afternoon. All medical associates and
friends of Doctor Becker’s are urged to attend.

Doctor Becker has been in general practice
in Blackwell since 1927. □

Braden Seeks New
OMPAC Members

Kent Braden, MD, Chairman of the Okla-
homa Medical Political Action Committee is
seeking new members for OMPAC. In a letter
to all OSMA members, he said, "The bitter
truth is simply this, the 1974 elections resulted
in the worst losses for the conservatives and
moderates since 1964, the Goldwater year.”

The Chairman of the Political Action Com-
mittee went on to state, "It was a loss, but not a
total defeat. It was a loss that can be countered
in 1976 if we begin working now!”

While asking all Oklahoma physicians to
join OMPAC as either regular members with
dues of $20 a year or sustaining members with
dues of $100 a year, he went on to point out, "It
is known that the chiropractors in some states,
including Oklahoma, have collected as much
as $500 per member to support candidates es-
pousing their philosophy, we can afford to do
no less.”

OMPAC memberships or inquiries may be
directed to P.O. Box 18759, Oklahoma City,
Oklahoma, 73118. □

Journal / May 1975 / Volume 68

181

news

Book Review

HAIR TRANSPLANT SURGERY — by
O’tar T. Norwood, MD, Assistant Clinical
Professor of Dermatology University of
Oklahoma Medical School, Oklahoma City,
Oklahoma. First Edition, 108pp., Spring-
field, Illinois. Charles C. Thomas-Publisher,
1973

This text of hair transplant surgery is di-
vided into ten chapters. The first chapter con-
sists of a classification of male pattern bald-
ness. This classification should be very helpful
to the physician in choosing his candidates for
hair transplant surgery.

Chapters 2 and 3 deal with the initial inter-
view of the patient and the physician’s criteria
in selecting candidates for the procedure. The
hand-out sheets for the patient should answer
many of the questions the patient may ask. I
think a more complete medical history and
physical examination is warranted than that
which is mentioned in the book. In particular, I
think a medical history of diabetes, psychologi-
cal disorders and other general diseases should
be documented before beginning the procedure.

Chapters 4, 5 and 6 deal with organization
and planning, the surgical procedure, and

complications. These chapters serve as an ex-
cellent guideline of the step-by-step technique
of hair transplantation.

Chapter 7 discusses the use of hair trans-
plants in alopecia other than male pattern
baldness.

The size of punches used for the surgery is
thoroughly covered with a special chapter (8)
devoted to the use of the 5 millimeter punch.

Chapter 9, polling many of the physicians
doing hair transplants, should alert the reader
to possible complications which he may en-
counter in doing the surgery.

The final chapter deals with the current
status of hair-bearing homografts and organ
transplantation.

The black and white photography through-
out the text is of good quality but the color
photograph section is of poor quality and, in
my opinion, should be replaced by black and
white photographs or left out altogether.

Doctor Norwood’s book is a thorough text on
the subject of hair transplantation and should
be in the library of any physician interested in
hair transplantation surgery. He deserves
congratulations for compiling information on a
very timely surgical procedure. Julian W.
Swann, MD, Assistant Professor of Medicine ,
Dermatology Division, Emory University
School of Medicine, Atlanta, Georgia. □

SEVENTH ANNUAL

ARKANSAS-OKLAHOMA CANCER FORUM

September 25th-26th, 1975 Fort Smith, Arkansas

This one and one-half day meeting will be held at the Sheraton Snn in Fort Smith,
September 25th-26th, 1975.

Guest speakers from Memorial Hospital, New York City and the Sloan Kettering
Institute will highlight the program.

Further details to be announced later.

182

Oklahoma State Medical Association

auxiliary

Mrs. William B. Renfrow
Oklahoma City
President

Mrs. James L. Haddock
Norman
President-Elect

Mrs. Orange M. Welborn
Ada

Recording Secretary

Journal / May 1975 /

WOMAN’S AUXILIARY

to the

OKLAHOMA STATE MEDICAL ASSOCIATION

Officers 1975-1976

Mrs. Bryce Petrie
Oklahoma City
1st Vice-President

Mrs. Joseph W. Stafford
Enid

2nd Vice President

Mrs. Earl M. Bricker
Oklahoma City
Treasurer

Mrs. Ronald F. Gates
Tulsa

Treasurer-Elect

Volume 68

xxx vii

A public relations campaign to explain the
OSMA’s position regarding Utilization Review
is being prepared by a Tulsa Consulting Firm.
The campaign, authorized by the House of Del-
egates, will be based on the adverse effect the
new Utilization Review Regulations have on
patient care, ie, rationing of patient care and
the possible closure of small hospitals. The
American Medical Association has pledged to
furnish the state with technical assistance in
the preparation of the campaign.

The Oklahoma Medical Political Action
Committee took second place in national
competition for number of sustaining mem-
bers. It is significant that a small state like
Oklahoma can compete with such states as
California, Texas, and New York in competi-
tion for the number of sustaining members.
The award was presented publicly during
Oklahoma Medical Summit ’75 by Rex Ken-
yon, MD, a member of the national AMPAC
Board. It went to Ed Calhoon, MD, OMPAC
Chairman for last year and Kent Braden, MD,
this year’s chairman.

The American Medical Association’s

recently introduced national health insurance
plan, HR6222, is being described as "the only
substantially new approach . . . presented so
far in the 94th Congress.” The plan is called a
"Comprehensive Health Care Insurance Act.”
It deals on the present system of employer-em-
ployee group health insurance plans, mandat-
ing each employer to provide comprehensive
and catastrophic benefit coverage with the em-
ployer picking up at least 65 percent of the
cost. Medicare beneficiaries could purchase
supplemental insurance to bring their benefits
up to par with those offered elsewhere.

Congress has been told that federal inter-
vention in the professional liability crisis could
"create a worse situation and in some cases re-
sult in even higher liability costs.” AMA
President Malcolm C. Todd, MD, told the Sen-
ate Health Subcommittee headed by Senator
Kennedy that "it is far wiser for states to enact
varied innovative legislative responses to the
problem than to have an untested and unproved
scheme enacted on a nationwide basis by the

federal government, particularly where such
proposals contain elaborate provisions for fed-
eral government regulations of the practice of
medicine.” Todd’s remarks were echoed by
Richard E. Palmer, MD, Chairman of the AMA
Board of Trustees. He went on to say, "The
complexity of the problem, and its varied
causes convince us, however, there is no single
solution, be it arbitration, 'no fault’, or any-
thing else.”

Governor David Boren is actively involved

in a "selling” campaign to encourage Okla-
homa-educated physicians to stay in the state
to practice or return to the state if they sought
postgraduate education elsewhere. He has
written every OU College of Medicine gradu-
ate for the past five years who is out of state
urging them to return. The Governor’s efforts
are being coordinated by the Oklahoma Coun-
cil for Health Careers, Inc., a private non-profit
corporation that was originally started by the
Oklahoma State Medical Association. Its pur-
pose is to recruit young people into health
careers.

PSRO Law Amendments, proposed by the
AMA, were introduced earlier this month in
the United States Congress. The 19 Amend-
ments to the PSRO Law would clarify the pur-
pose and function of criteria of care, increase
safeguards to confidentiality, eliminate harsh
penalties, repeal overlapping Utilization Re-
view Programs recently advanced under other
sections of the Social Security Act, and extends
utilization review and medical audit pro-
grams to federal medical installations.

Number of Health Maintenance Organiza-
tions, originally touted as "the answer” to the
health care delivery problem, has begun to de-
cline. According to the Washington report on
Medicine and Health, "the Minneapolis Think
Tank that put Health Maintenance Organiza-
tions into the Health lexicon says a quarterly
survey shows that 'for the first time, HMO
numbers are declining slightly.’ The total
number of HMO’s in the country stood at 181
the first of this month (April), down 2 from
January. . .” On another front, one of the or-
ganizations that was a prime mover behind the
HMO’s, the AFL-CIO, is now criticizing HEW
for its implementation of the HMO Regula-
tions. The huge labor union now finds that the
regulations would weaken its power to bargain
for health care benefits. □

;

■

xxxviii

Oklahoma State Medical Association

S s

The

June

1975

Vol. 68, No. 6

of the Oklahoma State Medical Association

EDITORIAL BOARD

MARK R. JOHNSON, MD
Editor-m-Chief

HARRIS D. RILEY, Jr., MD
Editor

ROBERT G. TOMPKINS, MD
Editor

ERNEST LACHMAN, MD
Corresponding Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

OFFICERS

ARNOLD G. NELSON, MD
President

WILLIAM M. LEEBRON, MD
Vice-President

Haven W. Mankin, MD
Secreta ry -Treasurer

STAFF

DON BLAIR
Busin ess Manager

LOUISE MARTIN
Editorial Assistant

THE JOURNAL is the official publica-
tion of the Oklahoma State Medical Associa-
■ I1 tion, and is published monthly under the di-
, 1 rection of the Board of Trustees, 601 N.W.

Expressway, Oklahoma City, Okla. 73118.
) I Publication office (printer) 222 East Eufaula
|l St., Norman, Okla. 73069. Second-class
1 f postage paid at Oklahoma City, Okla-
, homa 73125.

SUBSCRIPTION TO THE JOURNAL is included in
® ! membership fees. Other subscriptions are
I $6.50 per year or $1.00 per copy with each
request subject to approval of the Editorial
0 1 Board.

,u i

CONTENTS

editorial

Letter From The Editor: I .... 183

President’s Page ....... 184

special

The Influence of Robert Burton and Clifford Whit-
tingham Beers On The Development of Psy-
chiatry, Steven C. Hardy and Virginia R. Allen,

PhD .

• • •

185

Gonorrhea :
1974 .

Recommended

Treatment Schedules-

189

News from
Health

the Oklahoma

State Department of

193

news

Constitutionality of PSRO Upheld By Federal

Court ......... 200

National Malpractice Situation Bad — Federal Inter-
vention Could Be Worse ..... 203

Hawaii Tour Filling Fast ...... 203

AMA Introduces New NHI Proposal in Congress . 204

Professional Liability Guide Again Available From

OSMA 205

Alcoholism Treatment Center In Cushing, Okla-
homa ......... 207

Medicare/ Medicaid Allowables To Be Reduced . 207

Doctors and Lawyers To Have Balkan Adventure . 208

MD Prescription Deficiencies Cause Pharmacists

Trouble . 209

Governor Boren Seeks Doctors For State . . 209

Deaths ......... 211

Oklahoma Affiliate Appointed By Ada . . . 211

Social Security May Be “Broke” by 1980 . . 211

Miscellaneous Advertisements ..... vii

Index To Advertisers ...... xxii

(Cover Art By William Cason)

iii

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notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

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Oklahoma State Medical Association

editorial

LETTER FROM THE EDITOR: I

To the Chairperson
Pre-admission Utilization
Review Committee
Community Hospital, USA

Dear Person:

It has come to my attention that your com-
mittee, acting in concert, has intervened in the
course of therapy which I have advised for my
patient, Mr. John Public, and, as a consequ-
ence, he has been refused admission to the hos-
pital.

The purpose of this letter is to advise you and
the members of your committee that, in my
personal and professional opinion, you have
assumed full responsibility for Mr. Public’s fu-
ture health care.

Prior to your unsolicited evaluation of his
condition and medical needs, Mr. Public had
been under my care and observation for a
period of twelve years. During that time, he
enjoyed relatively good health, was a coopera-
tive and well-motivated patient, and conscien-
tiously followed my advice in matters pertain-
ing to his health. In seeking admission to the
hospital he was, quite obviously, acting upon
my advice. Had I believed that any course of
action other than hospitalization would have
been more or equally beneficial I would not
have advised his admission.

As you and your committee members are
profesionally unknown to me, I know nothing
of your credentials. Certainly, I would never

Journal / June 1975 / Volume 68

advise any of my patients to follow the recom-
mendations of an anonymous interloper whose
qualifications, character and experience are, at
best, unverified.

I understand that you and your committee
members operate within a framework of laws
which provide you with certain immunities
which I do not share in my relationship with
Mr. Public. Notwithstanding this fact, I have
notified my patient, in writing, that because of
your actions, I can no longer be responsible for
his care. I prescribed hospitalization for him
and hospitalization is the only recommenda-
tion I have. Since you and your committee,
functioning as alien, uninvited consultants, di-
rected and paid by fiscal interests, have inter-
vened and made alternative recommendations
imperative, I am assuming you know of
and can recommend some alternatives which
are unacceptable to me.

Therefore, I have suggested to Mr. Public
that he contact you and follow your advice
about his future medical care. I have also ex-
plained to him that, even though we are not ac-
quainted, you must be a competent, dedicated
and exceptionally talented person because of
your extremely powerful and responsible posi-
tion.

I do hope you find this information helpful in
your subsequent care and management of Mr.
Public’s case. He is a fine person and I am sure
you will enjoy caring for him.

Very cordially yours,

Mark R. Johnson, MD MRJ

183

president's page

Since I took office as
President of the Okla-
homa State Medical As-
sociation, I have been
busy putting out one fire
after another. It has
been much like the pri-
vate practice of medicine
in that I have encountered
one emergency after
another. Each problem needs to be taken care of
in its own special manner.

The smoke had hardly cleared from the House
of Delegates Assembly Hall when we began
work carrying out the orders that had been
handed down by the delegates. With passage of
the resolution of non-participation in utiliza-
tion review as written in Federal Registry of
November 29, 1974, by Secretary Caspar Wein-
berger, it became necessary to attack that fire
first.

A strong Council on Public Policy was ap-
pointed with Doctor Joe Crosthwait as its
chairman. Some members of this council have
met several times weekly since their appoint-
ment. Doctor Crosthwait, Doctor Braden, Mr.
Ed Kelsay, Mr. David Bickham and I made a
flying trip to Washington, D.C. to meet with
Senator Henry Bellmon, Jay Constantine and a
dozen bureaucrats from the Department of
Health, Education and Welfare and related or-
ganizations. We felt that our meeting was a
success. At the present time, the Public Policy
Council is attempting to write a new, superior
and acceptable Utilization Review plan. By ac-
ceptable, I mean acceptable to the physicians of
Oklahoma and acceptable to Secretary Wein-
berger as a substitute U.R. plan for Oklahoma.
It will be necessary to carry out further negotia-
tions in Washington with the high officials of
HEW, namely Secretary Weinberger, when the
superior Oklahoma plan is completed.

The Council on Public Policy is also very busy
with plans for a public relations campaign to
educate the citizens of Oklahoma with respect
to the dangers of the federal utilization review
plan as it is written today.

SOME OF THE DANGERS ARE:

1. The hospital benefits promised by Congress
to the elderly and the poor would be sharply
reduced. Then I would say we would have a
rationing of care to the poor and the elderly.

2. The regulations as currently written by
Secretary Weinberger violate the rights of all
Medicare and Medicaid patients to receive
whatever treatment their physician feels is
best.

3. The regulations would invade the right of
privacy, concerning information given to their
physician in complete confidence.

4. The regulations as written could force as
many as 50 small Oklahoma hospitals to close.

5. HEW claims the regulations will improve
medical care. WJiat it really amounts to, is a
"cost control” program, at the expense of good
medical care for the poor and the elderly.

6. Rather than save money for our govern-
ment, it has been predicted that the admin-
istrative costs will increase far beyond any sav-
ings.

7. Implementation of these regulations would
take even more of the physicians time, there-
fore there would be even less time to spend with
patients.

I would be remiss in writing this President’s
Message if I did not make some remarks con-
cerning the Oklahoma Medical Summit, 1975. 1
thought it was the greatest medical meeting
ever assembled in Oklahoma. More than
one-third of the physicians of Oklahoma were in
attendance. Next year we must strive for an
even bigger and better meeting. Overall, I
thought Summit ’75 was a tremendous success
and I want to thank the Steering Committee,
the other committees and all who made it a
success. I want to thank the entire executive
staff as well as the secretarial staff for their
contributions, for without them it would have
been an impossible task.

184

Oklahoma State Medical Association

The Influence of Robert Burton
and Clifford Whittingham Beers
on the Development of Psychiatry

STEVEN C. HARDY
VIRGINIA R. ALLEN, PhD

The United States has pioneered in the
field of mental hygiene in the twentieth century.

Two laymen, one in the seventeenth
century and one in the early twentieth
century, made significant
contributions to its development.

William Osier regarded the modern period
as the age of preventive medicine.1 Discoveries
in bacteriology, hygiene, biochemistry, and nu-
trition led to significant advances in preven-
tive medicine and the prolongation of life. The
United States pioneered in a special field of
preventive medicine — the mass application of
mental hygiene — with the founding of a na-
tional hygiene movement in 1909.

Erwin Ackerknecht, historian of medicine,
viewed the resurgence of psychosomatic
medicine in the following light:

What appears to have happened is that
in the latter part of the nineteenth cen-
tury and the first half of the twentieth
century the old insights were lost in the

Journal / June 1975 / Volume 68

shuffle of fascinating objective discov-
eries with the attendant overmechaniza-
tion and overspecialization. Doctors
became so laboratory-minded, so scientific,
and so impersonal, that they forgot, or
felt entitled to ignore, the patient as a
person. It is a queer reflection on the
present age that one of the basic medical
functions of all times now had to be re-
introduced — as a new specialty.2
Two men, Robert Burton and Clifford Beers,
both non-physicians, made significant con-
tributions to the humanitarian application of
preventive medicine to mental hygiene. Al-
though widely separated in time, their work
had many similarities. Out of their individual
life experiences each brought forth an influen-
tial literary work. This literature reflected
their need to focus upon problems of the mind,
and those who treat patients with mental dys-
functions.

Robert Burton, the son of Dorothy Burton, a
chirurgeon, and Ralph Burton^ Esq., was born
on February 8, 1577 at Lindley, Leicestershire,
England. His schooling was at Sutton Cold-
field, Warwickshire, and at Nuneaton Gram-
mar School. The fourth of nine children, he
showed the signs of a depressive character
early in life, and felt he had been denied
affection.3 In 1593 Burton entered Brasenose
College, Oxford as a "commoner.” In 1599 he

185

Influence / HARDY, ALLEN

was elected student of Christ Church [College],
where he continued his scholarly activities
throughout his life. He received the degree of
Bachelor of Divinity in 1614. A vicarage in Ox-
ford and a rectory in a country parish provided
his living.4

Burton was by profession a divine, but by
inclination a physician. He devoted his life to
the study of mental aberrations and was con-
cerned with no other branch of medicine, un-
less it was related to this central interest.
Eighteen times during his forty-seven years at
Oxford he published Latin verses in various
college and university publications. A satirical
play, Philosophaster , was written in 1606 and
was performed at Christ Church in 1617. In
1621 he published his most important work,
The Anatomy of Melancholy . This brought rec-
ognition and wealth, but did not dispel his dis-
appointment with life, which resulted from ex-
cessive expectation rather than meager
accomplishment.6 He died on January 25,
1640, almost exactly at the time he had pre-
dicted. The epitaph, inscribed in Latin on his
tomb at Christ Church, summarizes his life:

Known to few, unknown to fewer,
here lies

Democritus Junior,

to whom melancholy gave both life and death.

Burton’s Anatomy was written in light of
contemporary medical science which had been
handed down from the great physicians of the
Greek culture — Hippocrates and Galen. The
body was thought to contain four humors:
blood, phlegm, choler (yellow bile), and melan-
choly (black bile). It was held that a proper
balance of the quantities of these humors
would result in good health, and their propor-
tions determined the complexion (tempera-
ment). When blood was uppermost a man was
sanguine; when phlegm was in excess he was
phlegmatic; when he had too much choler he
was bilious; and extra melancholy made him
atrabilious, or, if very disproportionate,
insane.7 The Anatomy of Melancholy begins
with these words:

The Anatomy of Melancholy, what it
is. With all the Kindes, Causes, Symp-
tomes, Prognostickes, and severall cures
of it. In Three Maine Partitions with their
severall Sections, Members, and Sub-
sections. Philosophically, Medicinally,

186

historically, opened and cut up. By Democ-
ritus lunior.8

Interpreters of Burton have found three
Robert Burtons. To early scholars such as
Thomas Fuller, Burton was the author of an
encyclopedia, "a miscellany of familiar and un-
familiar quotations, a source of rich material
for plagiarists.”9 Charles Lamb and other in-
terpreters through the nineteenth century saw
Burton as a "fantastic old man,” who was a
quaint literary stylist, and curious museum
piece.10 They seldom viewed him dis-
passionately, but usually with either adoration
or scorn. Twentieth century recognition of
Burton’s serious intention was due primarily
to William Osier, who was the first critic to
comprehend the real nature of Burton s work.
Three hundred years after it was written,
Osier spoke of The Anatomy as the greatest
medical treatise ever written by a layman.11
Osier’s interpretation bears a marked resem-
blance to Burton’s self-portrait — the
anatomist of melancholy.

Burton’s intent was to anatomize melan-
choly through all of its facets so that it could be
avoided. He knew of no better way to spend his
time than in prescribing the means of pre-
venting and curing the seemingly universal
malady of melancholy. Its universality was due
to a great extent to the economic crisis that
Jacobean England was experiencing. The
Anatomy of Robert Burtons England , by Wil-
liam Mueller, is a sociological study of the
economic, political, social, and religious blight
in which Burton lived. A psychological
analysis in Bergen Evans The Psychiatry of
Robert Burton reveals the perceptiveness of
Burton’s theories of psychiatry in the light of
modern psychological thought.

The compassion which underlies The
Anatomy was a result of the suffering endured
by Burton himself. It influenced his perception
of the need for the humane care which is now
regarded as indispensable for successful
treatment. Phillipe Pinel is generally credited
with being the first physician to appreciate the
necessity for kindness and sympathy in the
treatment of the insane and to institute ra-
tional methods of treatment. In 1795, Pinel, at
Salpetriere, removed the shackles from the
mentally ill and prescribed hospital care for
them. The acknowledgement of Pinel s
methods as a revolutionary milestone in the
course of psychiatry illustrates how completely
Burton’s plea, made a hundred and seventy
years earlier, had been disregarded.

Oklahoma State Medical Association

Burton understood quite clearly that mental
disturbances can be treated. He insisted that
the patient’s total situation must be taken into
consideration — his emotional state and at-
titudes, his intimate personal relationships,
his occupation and other activities, and his so-
cial environment. In this insistence, he antici-
pated the most modern conceptions. Only in
the past century have techniques for systema-
tic and coordinated medical, psychological, and
social studies of the neurotic or psychotic indi-
vidual been incorporated into the procedures of
psychiatric clinics.

The first coordinated medical effort at
psychiatric treatment occurred at the leading
medical center in the United States, Johns
Hopkins University and Hospital. There, Wil-
liam Osier introduced precise laboratory
methods and exact science into the field of clin-
ical medicine. Not only was Osier a leading
clinician, he was a "born humanist.”12 His
humanism in clinical medicine was influential
in the environment of Johns Hopkins, and his
intense interest in Robert Burton probably in-
duced many of his students and colleagues to
read The Anatomy . This exposure predisposed
the favorable reception of the well-penned
story of Clifford Whittingham Beers. Beers had
borne the ignorance, callousness, and irrespon-
sibility commonly found in insane asylums of
the late nineteenth century.

Clifford Beers was the fifth of six sons in a
modest and happy family in New Haven, Con-
necticut. He was a Yale College graduate with
an interest in business. In 1894, an elder
brother was stricken by epileptic convulsions.
Although the illness was later diagnosed as a
brain tumor, Beers had become obsessed with
the fear that he also would develop epilepsy.
His pent-up fears overwhelmed him into a
state of mental collapse and drove him to at-
tempt suicide in 1900. His desperate leap rid
him of his fear of epilepsy, but he began three
years of unreason, terror, ecstasy and suffering
which he vividly recounts in his book.13 Out of

Steven Hardy is a student at the University of
Oklahoma and will receive a BS in Zoology and
a BA in psychology in May, 1975. Doctor Allen
is an Instructor in History of Medicine at the
University of Oklahoma Health Sciences Center
and an Adjunct Instructor in History at the
University of Oklahoma. Mr. Hardy prepared a
draft of this paper during a course in the His-
tory of Biomedical Sciences.

his experiences, he gleaned the insight and in-
trospection to express his suffering through
writing. A Mind That Found Itself aided his
efforts to reform the fortresses of apathy and
abuse, which persisted in spite of the efforts of
Dorothea Dix and other reformers of the
mid-1900’s. Beers declared that the most im-
portant purpose of his book was to wage an
educative war against the prevailing ignor-
ance regarding insanity, and to promote the
role of mental hygiene in the curtailment of
mental dysfunction.

Beers began writing A Mind That Found It-
self in 1904, after being encouraged by Joseph
K. Choate, who told him that busy men might
read a book in their lesiure moments when
they would not take the time to listen to his
plans for reform. The manuscript at once won
the interest and active aid of William James,
and a year later the support of Adolf Meyer and
other outstanding leaders in psychiatry. Doc-
tor Meyer gave the name "mental hygiene” to
the movement whose planning and organiza-
tion consumed all of Beers’ energy.14 The book
also facilitated Beers’ founding of the Connec-
ticut Society for Mental Hygiene (1908), the
National Committee for Mental Hygiene
(1909), and the American Foundation for Men-
tal Hygiene (1928).

The Anatomy of Melancholy and A Mind
That Found Itself greatly influenced the envi-
ronment of Johns Hopkins. In Osier’s farewell
address at Johns Hopkins (1905), he specifi-
cally mentioned the urgent need for a
psychiatry department. A few years later Doc-
tor William H. Welch gave Henry Phipps a
copy of Beers’ book. The result was the funding
of the Henry Phipps Psychiatric Unit, which
opened in 1913. 15

Many parallel and contrasting facets of the
two men who produced these literary master-
pieces are apparent. Their lives were domi-
nated by their humanitarian interest in the
problems which plague men’s minds. Each had
personal psychiatric disorders. Although
Burton’s depression was not as severe, it was
prolonged. Beers’ acute mental illness was
relatively short-lived, but was accompanied by
attempted suicide and followed by a period of
severe manic-depression. Each plunged into a
career, Burton because of his scholarly nature,
and Beers because of his fear of a hereditary
disease. Burton recognized the humanitarian
needs of those suffering from mental disease;
Beers promoted fund-raising for the implemen-

Journal / June 1975 / Volume 68

187

Influence / HARDY, ALLEN

Beers than to nourish, vitalize, and carry for-
ward their work.

tation of research and the upgrading of fa-
cilities and services available to the mentally
ill. Burton gave his life to melancholizing, and
Beers gave his to mental hygiene.

What gave Burton’s work its psycho-
pathological importance was his ability to look
objectively into the mentality of the melan-
cholic. His insight was a forerunner of the de-
velopment of a comprehensive pathology of de-
pression, with self-destructive hostility as its
core. The therapeutic value of the modern con-
cept of transference was recognized by Burton
when he advised: "A friend’s counsel is a
charm, like mandrake wine, it allayeth our
cares. . . .

The preface to the twenty-ninth printing in
1944 of A Mind That Found Itself points out
the continuing need for concerted effort in
mental hygiene:

"We face a troubled world, its unhappy
difficulties due in great, perhaps great-
est part, to the mental, physical and moral
maladjustments of its peoples . . •
But mental hygiene has not as yet
been far enough advanced to play its
essential part. When it has been, and the
coordinated efforts of those who heal
the mind, of those who heal the body, and
of those who heal the soul are brought to
bear upon our world problems, shall we
not see the beginnings of a brighter day
the rise of a finer and more stable civil-
ization?”17

No better tribute can be made to Burton and

ACKNOWLEDGEMENTS

Special thanks goes to Doctor R. Palmer Howard,
Professor of History of Medicine and of Medicine,
University of Oklahoma Health Sciences Center, for
suggesting the topic and for editorial assistance.
Work in the History of Medicine is partly supported
by grants from the National Library of Medicine,
National Institutes of Health (Grant LM01396), the
Oklahoma Medical Research Foundation, and the
University of Oklahoma Foundation.

FOOTNOTES

1. William Osier, "Medicine in the Nineteenth Century, in Aequanimitas
With Other Addresses, (Philadelphia: Blakiston Company, 1904), pp. 226-227.
Also, Erwin H. Ackerknecht, A Short History of Medicine (New York: The
Ronald Press Company, 1968), p. 211.

2. Ackerknecht, p. 236.

3. Bergen Evans, The Psychiatry of Robert Burton (New York: Columbia

University Press, 1944), p. 7. ,

4. Sir Sidney Lee, ed., The Dictionary of National Biography (London: Oxford

University Press, 1920), Vol. Ill, p. 464.

5. Evans, pp. 4-5.

6. Evans, pp. 10-11.

7. Paul Jordan-Smith, Bibliographia Burtomana (Stanford: Stanford Uni-
versity Press, 1931), pp. 19-20.

8. Jordan-Smith, p. 80.

9. William R. Mueller, The Anatomy of Robert Burtons England (Berkeley:
University of California Press, 1952), p. 1.

10. Mueller, p. 1. „ ,

11. William Osier, A Way of Life (New York: Dover Publications, Inc., 1958),
p. 90; for discussion of Osier’s interest in Burton see Nicholas Dewey, "Sir
William Osier and Robert Burton’s Anatomy of Melancholy,” Journal of the
American Medical Association, 210; 12 (Dec. 22, 1969), pp. 2245-2250.

12. Henry E. Sigerist, The Great Doctors (Garden City, N.Y.: Doubleday and
Company, Inc.,- 1958), p. 385.

13. Clifford W. Beers, A Mind That Found Itself: An Autobiography (New
York: Longmans, Green and Co., 1908).

14 David K Henderson, Introduction, Eunice E. Winters, ed.: The Collected
Papers of Adolf Meyer (Baltimore: The Johns Hopkins University Press, 1951),
Vol. II, p. xix.

15. Winters, pp. 218-220.

16. Robert Burton, The Anatomy of Melancholy (New York: Tudor Pub-
lishing Co., 1927), p. 471. . _ .

17. Paul O. Komora, Editor’s Preface to 29th Printing, in C. W. Beers, A
Mind That Found Itself ( Garden City, N.Y.: Doubleday and Co., 1943).

Virginia R. Allen, PhD, P.O. Box 26901, Ok-
lahoma City, Oklahoma 73190

NOW AVAILABLE

PROFESSIONAL LIABILITY
MEDICAL — LEGAL GUIDE FOR PHYSICIANS

PUBLISHED BY

OKLAHOMA STATE MEDICAL ASSOCIATION

This booklet was prepared by the staff of
the OSMA in 1969 and was published by the
Insurance Company of North America for
distribution to all medical doctors in the
state. It has now been republished and is
available upon request.

Requests for the book should be directed to
the Oklahoma State Medical Association,
601 Northwest Expressway, Oklahoma City,
Oklahoma 73118.

There is no charge for this booklet.

188

Oklahoma State Medical Associatio

special

notice

GONORRHEA

Recommended Treatment
Schedules— 1974

Physicians are cautioned to use no less than
the recommended dosages of antibiotics.

UNCOMPLICATED GONOCOCCAL
INFECTIONS IN MEN AND WOMEN

Drug Regimen of Choice:

Aqueous procaine penicillin G (APPG), 4.8
million units intramuscularly, divided into at
least two doses and injected at different sites at
one visit, together with one gram of prob-
enecid, by mouth, just before the injections.

Alternative Regimens:

A. Patients in whom oral therapy is pre-
ferred: Ampicillin, 3.5 gm, by mouth, together
with one gram probenecid by mouth, adminis-
tered at the same time. There is evidence that
this regimen may be slightly less effective than
the recommended APPG regimen.

B. Patients who are allergic to the penicillins
(penicillin G, ampicillin) or probenecid*:

1. Tetracycline hydrochloride, 1.5 gm ini-
tially by mouth, followed by 0.5 gm by mouth
four times per day for 4 days (total dosage, 9.5
gm). Other tetracyclines are not more effective
than tetracycline hydrochloride. All tetra-

* Allergy to penicillin, ampicillin, probenecid, or previous anaphylactic reac-
tion.

Department of Health, Education and Welfare, Public Health Service, Cen-
ter for Disease Control, Atlanta, Georgia 30333.

Oil

cyclines are ineffective as single-dose therapy.

2. Spectinomycin hydrochloride, 2.0 gm
intramuscularly, in one injection.

Treatment of Sexual Partners:

Men and women with known recent ex-
posure to gonorrhea should receive the same
treatment as individuals known to have
gonorrhea. Male sex partners of persons with
gonococcal infection must be examined and
treated because of the high prevalence of
nonsymptomatic urethral gonococcal infection
in such men.

Followup:

Followup urethral and other appropriate
cultures should be obtained from men, and cer-
vical, anal and other appropriate cultures
should be obtained from women, 7 to 14 days
after completion of treatment.

Treatment Failures:

Most recurrent infection after treatment
with the recommended schedules is due to rein-
fection. True treatment failure after therapy
with penicillin, ampicillin or tetracycline
should be treated with 2.0 gm of spectinomycin
intramuscularly.

Postgonococcal Urethritis:

Tetracycline, 0.5 gm, four times daily by
mouth, for at least 7 days.

Journal / June 1975 / Volume 68

189

Gonorrhea

Pharyngeal Infection:

Pharyngeal gonococcal infections may be
more difficult to treat than anogenital
gonorrhea. Post- treatment cultures are essen-
tial followup for pharyngeal infection. The
schedules of ampicillin and spectinomycin rec-
ommended for anogenital gonorrhea are in-
effective in pharyngeal gonorrhea. Patients
with pharyngeal gonorrhea whose infection is
not eradicated after treatment with 4.8 million
units of APPG plus one gram of probenecid,
may be treated with 9.5 gm of tetracycline in
the dosage schedule outlined above (Alterna-
tive Regimens).

Syphilis:

All patients with gonorrhea should have a
serologic test for syphilis at the time of diag-
nosis. Seronegative patients without clinical
signs of syphilis, who are receiving the recom-
mended parenteral penicillin schedule, need
not have followup serologic tests for syphilis.
Patients treated with ampicillin, spectinomy-
cin, or tetracycline should have a followup
serologic test for syphilis after 3 months to de-
tect untreated syphilis.

Patients with gonorrhea who also have
syphilis should be given additional treatment
appropriate to the stage of syphilis.

Not Recommended:

Although long-acting forms of penicillin
(such as benzathine penicillin G) are effective
in syphilotherapy, they have NO place in the
treatment of gonorrhea. Oral penicillin prep-
arations such as penicillin V are not recom-
mended for the treatment of gonococcal infec-
tion.

TREATMENT OF UNCOMPLICATED
GONORRHEA IN PREGNANT PATIENTS

A. For women who are not allergic to penicil-
lin: Use the regimens of aqueous procaine
penicillin G plus probenecid, or use ampicillin
plus probenecid, as defined above.

B. Pregnant patients who are allergic to
penicillins (there are several possible alterna-

tive regimens, each of which has potential dis- i
advantages):

1. Erythromycin, 1.5 gm orally, followed by

0.5 gm four times a day for 4 days, for a total of
9.5 gm. This regimen is safe for mother and
fetus, but efficacy has not been established.
Erythromycin estolate should not be used in
patients with underlying liver disease.

2. Cefazolin, 2 gm intramuscularly, with 1.0
gm of probenecid. Because of the possibility of
cross-allergenicity between penicillins and
cephalosporins, this regimen should not be
used in a patient with a history of penicillin
anaphylaxis.

3. Spectinomycin, 2 gm intramuscularly.
This is an effective dose, but safety for the fetus
has not been established.

Contraindicated:

Tetracycline should not be used for un-
complicated gonococcal infection in pregnancy
because of potential toxic effects for mother
and fetus.

ACUTE SALPINGITIS (PELVIC
INFLAMMATORY DISEASE)

The diagnosis of acute salpingitis should be
considered in women with acute lower ab-
dominal pain and adnexal tenderness on pelvic
examination. Since there are no completely re-
liable clinical criteria on which to distinguish
gonococcal from nongonococcal salpingitis, en-
docervical cultures for N. gonorrhoeae are es-
sential in such patients. Therapy, however,
should be initiated immediately, without wait-
ing for the results of the cultures.

A .Hospitalization: Hospitalization should be
strongly considered for women with suspected
salpingitis in these situations:

1. Uncertain diagnosis, where surgical
emergencies must be excluded.

2. Suspicion of pelvic abscess.

3. Pregnant patients with salpingitis.

4. Inability of the patient to follow an out-
patient regimen of oral medication, especially
because of nausea and vomiting.

5. Failure to respond to outpatient therapy.
B. Antimicrobial Agents: Controlled studies

of the treatment of acute salpingitis are not
available. Initial management must AT
LEAST be adequate for gonococcal salpingitis.
These regimens are known to be adequate for
the treatment of gonococcal salpingitis:

190

Oklahoma State Medical Association

1. Outpatients:

a. 1.5 gm tetracycline hydrochloride, given
as a single oral loading dose, followed by 500
mg, taken orally, four times daily for 10 days.

b. Aqueous procaine penicillin G (APPG), 4.8
million units intramuscularly, divided into at
least two doses and injected at different sites at
one visit, OR 3.5 gm of oral ampicillin. One
gram of oral probenecid is given along with
either penicillin or ampicillin, and both are fol-
lowed by 500 mg of ampicillin, taken orally,
four times daily for 10 days.

2. Hospitalized patients:

a. Aqueous crystalline penicillin G, 20 mil-
lion units, given intravenously each day until
clear-cut improvement occurs, followed by 500
mg of ampicillin, taken orally, four times daily,
to complete 10 days of therapy. The need for
additional or alternative antibiotics for the
treatment of nongonococcal salpingitis re-
quires further study. Since it is impossible to
distinguish gonococcal from nongonococcal
salpingitis clinically, many physicians also use
an aminoglycoside in addition to penicillin
and/or antibiotics which are effective against
Bacteroides fragilis as initial therapy.

b. Tetracycline hydrochloride, 500 mg, given
intravenously four times daily until improve-
ment occurs, followed by 500 mg taken orally
four times daily, to complete 10 days of
therapy. This regimen should not be used for
pregnant women or for patients with renal
failure.

3. Failure to improve on the recommended
regimens does not necessarily indicate the
need for stepwise additional antibiotics, but
requires reassessment of the possibility of
other diagnoses and of the specific microbial
etiology.

C. The effect of the removal of an in-
trauterine device on the response of acute sal-
pingitis to antimicrobial therapy and on the
risk of recurrent salpingitis requires further
study.

D. Adequate treatment of women with acute
gonococcal salpingitis must include examina-
tion and appropriate treatment of their male sex
partners because of the high prevalence of non-
symptomatic urethral gonococcal infection in
such men. Failure to treat male sex partners is a
major cause of recurrent gonococcal salpingitis.

E. Followup of patients with acute salping-
itis is essential. All patients should receive re-

peat pelvic examinations and cultures for N.
gonorrhoeae after treatment.

DISSEMINATED GONOCOCCAL
INFECTION

A. Equally effective treatment schedules in
the arthritis-dermatitis syndrome include:

1. Aqueous crystalline penicillin G, 10 mil-
lion units intravenously per day for 3 days, or
until there is significant clinical improvement.
This may be followed with ampicillin, 500 mg
four times a day orally, to complete 7 days of
antibiotic treatment.

2. Ampicillin, 3.5 gm orally, plus probenecid,
1.0 gm, followed by ampicillin, 500 mg four
times per day orally, for at least 7 days.

B. In penicillin and/or probenecid allergic
patients:

1. Tetracycline, 1.5 gm orally, followed by
500 mg four times a day orally, for at least 7
days. Tetracycline should not be used for com-
plicated gonococcal infection in pregnancy be-
cause of potential toxic effects for mother and
fetus.

2. Erythromycin, 0.5 gm intravenously every
6 hours, for at least 3 days.

C. Additional measures:

1. Hospitalization is indicated in patients
who are unreliable, have uncertain diagnosis,
or have purulent joint effusions or other com-
plications.

. Immobilization of the affected joint(s) ap-
pears helpful. Repeated aspirations and saline
irrigations appear beneficial, but controlled
studies of these procedures have not been per-
formed. Open drainage of joints other than the
hip is now generally discouraged in patients
with gonococcal arthritis.

3. Intra-articular administration of penicil-
lin is unnecessary, since penicillin levels in the
synovial fluid of inflamed joints approximate
serum levels; furthermore, intra-articular in-
jection per se may produce a toxic synovitis.

D. Meningitis and endocarditis due to the
gonococcus require high-dose intravenous
penicillin therapy (at least 10 million units per
day) for longer periods: usually at least 10 days
for meningitis and 3-4 weeks for endocarditis.

GONOCOCCAL INFECTION IN
PEDIATRIC PATIENTS

Pediatric patients encompass those from
birth to adolescence. When a child is post-

Journal / June 1975 / Volume 68

191

Gonorrhea

pubertal and/or weighs over 100 pounds, he or
she should be treated with dosage regimens as
defined above for adults.

WITH GONOCOCCAL INFECTION IN
CHILDREN, THE POSSIBILITY OF CHILD
ABUSE MUST BE CONSIDERED!

The efficacy of therapeutic regimens for un-
complicated and complicated gonococcal infec-
tions of childhood is unproven at present.

Prevention of Neonatal Infection:

All pregnant women should have endocervi-
cal cultures examined for gonococci as an in-
tegral part of prenatal care.

Prevention of Gonococcal Ophthalmia:

A. One percent silver nitrate (do not irrigate
with saline, as this may reduce efficacy).

B. Ophthalmic ointments containing tet-
racycline, erythromycin, or neomycin are also
probably effective.

C. NOT RECOMMENDED: Bacitracin
ointment (not effective) and penicillin drops
(sensitizing).

Management of Infants Born to Mothers
With Gonococcal Infection:

Orogastric and rectal cultures should be
taken from all patients. Blood cultures should
be taken if septicemia is suspected. Aqueous
crystalline penicillin G, 50,000 units/kg/day,
should be administered in two daily doses in-
travenously, if cultures or Gram-stained
smears reveal onococci. The duration of
therapy should be determined by clinical re-
sponse. In suspected septicemia, an aminog-
lycoside should also be administered.

Neonatal Disease:

A. Gonococcal ophthalmia: Patient should be
hospitalized. Antimicrobial agents: Aqueous
crystalline penicillin G, 50,000 units/kg/day, in
two or three doses intravenously for 7 days,
PLUS frequent saline irrigations and instilla-
tion of penicillin, tetracycline or chloram-
phenicol eyedrops.

B. Complicated infection: Arthritis and sep-
ticemia should be treated by hospitalization

192

and administration of aqueous crystalline
penicillin G, 75,000-100,000 units/kg/day, in
four doses, or procaine penicillin G,
75,000-100,000 units/kg/day, in two doses, for 7
days. Meningitis should be treated with aque-
ous crystalline penicillin G, 100,000
units/kg/day, divided into two or three daily
intravenous doses and continued for at least 10
days.

Childhood Disease:

Gonococcal ophthalmia should be treated
with hospitalization and by the administration
of aqueous crystalline penicillin G intraven-
ously, 75,000-100,000 units/kg/day, in four
doses, or procaine penicillin G, intramuscu-
larly, 75,000-100,000 units/kg/day, in two
doses, for 7 days, PLUS saline irrigations and
instillation of penicillin, tetracycline or
chloramphenicol eyedrops. Topical antibiotics
alone are NOT recommended in therapy of
gonococcal ophthalmitis. The source of the in-
fection must be identified.

Uncomplicated vulvovaginitis and urethritis
usually do not require hospitalization. Both
may be treated at one visit with aqueous pro-
caine penicillin G, 75,000-100,000 units/kg in-
tramuscularly, and probenecid, 25 mg/kg by
mouth. Topical and systemic estrogen therapy
are of no benefit in vulvovaginitis. All patients
should have followup cultures, and the source
of infection should be identified, examined and
treated.

Infection complicated by peritonitis or
arthritis should be treated by hospitalization
and administration of aqueous crystalline
penicillin G, intravenously, 75,000-100,000
units/kg/day, in four doses, or procaine penicil-
lin G, 75,000-100,000 units/kg/day intramus-
cularly, in two doses for 7 days.

Treatment of patients with allergy to
penicillin: Patients under 6 years of age should
be treated with erythromycin, 40 mg/kg/day, in
four doses by mouth, for 7 days, for uncompli-
cated disease. Complicated disease should be
treated with cephalothin, 60-80 mg/kg/day in
four doses intravenously, for 7 days. Patients
older than 6 may be treated with an oral regi-
men of tetracycline, 25 mg/kg, as an initial
dose, followed by 40-60 mg/kg/day in four
doses, for 7 days, or an intravenous regimen
consisting of tetracycline, 15-20 mg/kg/day, in
four doses, for 7 days. ^

Oklahoma State Medical Association

Diagnosis Specificity of
Culture for Gonorrhea

Among the tools available to the physician
in the clinical laboratory, the culture for Neis-
seria gonorrheae is among the most specific.
False positive gonorrhea cultures are rare (1%
or less). Therefore, when a physician treats a
patient for gonorrhea on the basis of a positive
culture, he can be 99% sure he is treating the
patient appropriately. The physician must rely
heavily on the culture results, since 80% of
females with gonorrhea are asymptomatic.

Guidelines followed by the U.S. Public
Health Service and the State Department of
Health in the diagnosis of uncomplicated
gonorrhea in women are these:

1. Obtain culture from cervical os (rectal cul-
ture may be done at the same time);

2. Immediately inoculate an appropriate
medium (eg Thayer-Martin plates or Trans-
grow);

3. Pre-incubate specimens that are being
sent to a reference laboratory;

4. An isolate obtained in the above fashion is

COMMUNICABLE DISEASES IN OKLAHOMA FOR APRIL, 1975

DISEASE

April

1975

April

1974

March

1975

Total To Date
1975 1974

Amebiasis

Brucellosis

—

Chickenpox

159

114

205

674

528

Encephalitis, Infectious

Gonorrhea (Use Form ODH-228)

1104

980

1046

4069

3385

Hepatitis, A, B, Unspecified

316

389

Leptospirosis

—

Malaria

—

Meningococcal Infections

Meningitis, Aseptic

Mumps

256

Rabies in Animals

Rheumatic Fever

—

Rocky Mountain Spotted Fever

—

Rubella

Rubella, Congenital Syndrome

—

Rubeola

Salmonellosis

Shigellosis
Syphilis, Infectious

148

(Use. Form ODH-228)

Tetanus

—

Tuberculosis, New Active

110

Tularemia

—

Typhoid Fever

—

Whooping Cough

—

News From
The Oklahoma State
Department of
Health

identified as N. gonorrheae on the basis of (a)
oxidase positivity; (b) colony morphology; (c)
appearance on gram stain.

If these guidelines are followed, 1% or less of
isolates identified as N. gonorrheae will be
false positives.

The chances of obtaining a false negative
gonorrhea culture are approximately 10%,
under ideal conditions.

A repeat culture performed because the
physician doubts that a given female patient is
infected can be seriously misleading. A posi-
tive culture result is 99% reliable; the chances
of confirmation are less than 90%. There is no
advantage in reculturing a culture-positive pa-
tient prior to treatment. There is considerable
risk of failing to diagnose an infectious patient
by doing so. □

Journal / June 1975 / Volume 68

193

SEVENTH

ANNUAL

ARKANSAS-

OKLAHOMA

CANCER

FORUM

September 25th-26th, 1975
Fort Smith, Arkansas

This one and one-half day meeting will be
held at the Sheraton Inn in Fort Smith, Sep-
tember 25th-26th, 1975.

Guest speakers from Memorial Hospital, New
York City and the Sloan Kettering Institute
will highlight the program.

Further details to be announced later.

Pro-Banthine®

brand of

propantheline bromide

Indications: Pro-Banthine is effective as
adjunctive therapy in the treatment of peptic
ulcer. Dosage must be adjusted to the
individual.

Contraindications: Glaucoma, obstructive
disease of the gastrointestinal tract,
obstructive uropathy, intestinal atony, toxic
megacolon, hiatal hernia associated with
reflux esophagitis, or unstable cardiovascular
adjustment in acute hemorrhage.

Warnings: Patients with severe cardiac
disease should be given this medication
with caution. Fever and possibly heat stroke
may occur due to anhidrosis.

Overdosage may cause a curare-like action,
with loss of voluntary muscle control.

For such patients prompt and continuing
artificial respiration should be applied until
the drug effect has been exhausted.

Diarrhea in an ileostomy patient may indicate
obstruction, and this possibility should be con-
sidered before administering Pro-BanthTne.
Precautions: Since varying degrees of urinary
hesitancy may be evidenced by elderly males
with prostatic hypertrophy, such patients
should be advised to micturate at the time
of taking the medication.

Overdosage should be avoided in patients
severely ill with ulcerative colitis.

Adverse Reactions: Varying degrees of
drying of salivary secretions may occur as
well as mydriasis and blurred vision. In
addition the following adverse reactions have
been reported: nervousness, drowsiness,
dizziness, insomnia, headache, loss of the
sense of taste, nausea, vomiting, constipation,
impotence and allergic dermatitis.

Dosage and Administration: The
recommended daily dosage for adult oral
therapy is one 15-mg. tablet with meals and
two at bedtime. Subsequent adjustment to
the patient’s requirements and tolerance
must be made.

How Supplied: Pro-BanthTne is supplied as
tablets of 15 and 7.5 mg., as prolonged-
acting tablets of 30 mg. and, for parenteral
use, as serum-type vials of 30 mg.

Searle & Co.

San Juan, Puerto Rico 00936

Address medical inquiries to: G. D. Searle & Co.

Medical Department, Box 5110, Chicago, III. 60680 481

SEARLE

194

Oklahoma State Medical Association

OSMA Publications Available

Rondomycin

(methacycline HCI)

CONTRAINDICATIONS: Hypersensitivity to any of the tetracyclines.

WARNINGS: Tetracycline usage during tooth development (last half of pregnancy to eight
years) may cause permanent tooth discoloration (yellow-gray-brown), which is more
common during long-term use but has occurred after repeated short-term courses.
Enamel hypoplasia has also been reported. Tetracyclines should not be used in this age
group unless other drugs are not likely to be effective or are contraindicated.
Usage in pregnancy. (See above WARNINGS about use during tooth development.)

Animal studies indicate that tetracyclines cross the placenta and can be toxic to the de-
veloping fetus (often related to retardation of skeletal development). Embryotoxicity has
also been noted in animals treated early in pregnancy.

Usage in newborns, infants, and children, (See above WARNINGS about use during
tooth development.)

All tetracyclines form a stable calcium complex in any bone-forming tissue, A decrease
in fibula growth rate observed in prematures given oral tetracycline 25 mg/kg every 6
hours was reversible when drug was discontinued
Tetracyclines are present in milk of lactating women taking tetracyclines.

To avoid excess systemic accumulation and liver toxicity in patients with impaired renal
function, reduce usual total dosage and, if therapy is prolonged, consider serum level de-
terminations of drug. The anti-anabolic action of tetracyclines may increase BUN. While
not a problem in normal renal function, in patients with significantly impaired function,
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acidosis.

Photosensitivity manifested by exaggerated sunburn reaction has occurred with tetra-
cyclines. Patients apt to be exposed to direct sunlight or ultraviolet light should be so ad-
vised, and treatment should be discontinued at first evidence of skin erythema.
PRECAUTIONS: If superinfection occurs due to overgrowth of nonsusceptible organisms,
including fungi, discontinue antibiotic and start appropriate therapy.

In venereal disease, when coexistent syphilis is suspected, perform darkfield exami-
nation before therapy, and serologically test for syphilis monthly for at least four months.

Tetracyclines have been shown to depress plasma prothrombin activity: patients on an-
ticoagulant therapy may require downward adjustment of their anticoagulant dosage
In long-term therapy, perform periodic organ system evaluations (including blood,
renal, hepatic).

Treat all Group A beta-hemolytic streptococcal infections for at least 10 days.

Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, avoid
giving tetracycline with penicillin.

ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms): anorexia, nausea,
vomiting, diarrhea, glossitis, dysphagia, enterocolitis, inflammatory lesions (with mond-
ial overgrowth) in the anogenital region.

Skin: maculopapular and erythematous rashes: exfoliative dermatitis (uncommon). Pho-
tosensitivity is discussed above (See WARNINGS).

Renal toxicity: rise in BUN, apparently dose related (See WARNINGS).

Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura,
pericarditis, exacerbation of systemic lupus erythematosus.

Bulging fontanels, reported in young infants after full therapeutic dosage, have disap-
peared rapidly when drug was discontinued.

Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosinophilia.

Over prolonged periods, tetracyclines have been reported to produce brown-black mi-
croscopic discoloration of thyroid glands: no abnormalities of thyroid function studies are
known to occur.

USUAL DOSAGE: Adults — 600 mg daily, divided into two or four equally spaced doses.
More severe infections: an initial dose of 300 mg followed by 150 mg every six hours or
300 mg every 12 hours. Gonorrhea: In uncomplicated gonorrhea, when penicillin is con-
traindicated, Rondomycin' (methacycline HCI) may be used for treating both males and
females in the following clinical dosage scnedule. 900 mg initially, followed by 300 mg
q i d fora total of 5.4 grams.

For treatment of syphilis, when penicillin is contraindicated, a total of 18 to 24 grams of
'Rondomycin' (methacycline HCI) in equally divided doses over a period of 10-15 days
should be given. Close follow-up, including laboratory tests, is recommended.

Eaton Agent pneumonia: 900 mg daily for six days.

Children - 3 to 6 mg/lb/day divided into two to four equally spaced doses.

Therapy should be continued for at least 24-48 hours after symptoms and fever have
subsided.

Concomitant therapy: Antacids containing aluminum, calcium or magnesium impair ab-
sorption and are contraindicated. Food and some dairy products also interfere. Give drug
one hour before or two hours after meals. Pediatric oral dosage forms should not be
given with milk formulas and should be given at least one hour prior to feeding.

In patients with renal impairment (see WARNINGS) . total dosage should be decreased
by reducing recommended individual doses or by extending time intervals between
doses

In streptococcal infections, a therapeutic dose should be given for at least 10 days.
SUPPLIED: Rondomycin (methacycline HCI): 150 mg and 300 mg capsules: syrup con-
taining 75 mg/5 cc methacycline HCI.

Before prescribing, consult package circular or latest PDR information.

Rev. 6/73

«5t&

if WALLACE PHARMACEUTICALS
CRANBURY. NFW JERSEY 08512

The following publications are available to
OSMA members free of charge. Requests for the
publications should be directed to the Okla-
homa State Medical Association, 601 North-
west Expressway, Oklahoma City, Oklahoma
73118.

PROFESSIONAL LIABILITY MEDICAL-
LEGAL GUIDE FOR PHYSICIANS: This is a
36-page booklet written to assist physicians in
preventing medical malpractice difficulties.

DRUG ABUSE TREATMENT MANUAL:
Prepared by the OSMA Alcoholism and Drug
Committee to assist physicians in handling, on
a short-term basis, drug involved patients.

INDEPENDENT PRACTITIONERS UN-
DER MEDICARE: A report to United States
Congress from the Health, Education and Wel-
fare Department regarding the practice of
chiropractic. It is an indictment of this unscien-
tific cult.

MEDICAL-LEGAL INTERPROFESSION-
AL CODE: This is the standards of coopera-
tion between physicians and attorneys that
have been mutually adopted by the OSMA
and the Oklahoma Bar Association.

MEDICAL NEWS PRACTICES: The stand-
ards of cooperation among physicians, hospitals
and the press of Oklahoma, specifying the
amount and types of information to be released
regarding patients. It was jointly adopted by the
Oklahoma Press Association, hospital associa-
tion, and medical association.

FOR PHYSICIANS AND PHARMACISTS:
This is the code of understanding between the
Oklahoma Pharmaceutical Association and the
medical association and specifies the relation-
ship between the two professions.

All of the above materials may be ordered by
OSMA members free of charge □

Journal / June 1975 / Volume 68

199

news

Constitutionality of PSKO Upheld
By Federal Court

In a major test of the constitutionality of the
Professional Standards Review Organization, a
special three-judge federal court in Chicago has
ruled in PSRO’s favor. The ruling dismissed a
suit filed in June, 1973, by the Association of
American Physicians and Surgeons against
HEW and the PSRO law.

In handing down its decision on May 8th, the
three-judge panel said, "in upholding the con-
stitutionality of the legislation on its face, this
court does not reach the validity of the statute
as it will be applied. Nor does this court pass
upon the wisdom of this particular piece of legis-
lation. Whether the implementation and appli-
cation of this statute may result in an unwieldy
bureaucracy of monstrous proportions is a pol-
icy question for the consideration of the legisla-
tive rather than the judicial branch of the gov-
ernment.” (Emphasis added)

A spokesman for the AAPS stated that attor-
neys for the organization are reviewing the
36-page memorandum explaining the court’s
dismissal to determine whether or not to appeal
the ruling to a higher court. He did state, how-
ever, that the organization intends to "pursue
all legal remedies.”

The suit as filed charged that the PSRO law
violated the first, fourth, fifth, and ninth
amendments to the Constitution by interfering
with patients’ and physicians’ privacy, interfer-
ing with physician rights to practice their pro-
fession, and by not providing adequate due pro-
cess to challenge PSRO decisions.

The three federal judges were William F.
Pell, Thomas R. McMillen, and William J.
Lynch, all sitting in the Northern District of
Illinois, Eastern Division of the Federal Court.
They took each of the AAPS’s seven contentions
and discussed them individually. The following
are excerpts from the memorandum of decision
that accompanied the federal court order.

The AAPS contended that the legislation vio-
lated the Fifth Amendment to the Constitution

200

in that it unconstitutionally interferes with
their right to practice medicine. In response the
court stated, "the Professional Standards Re-
view Law does not prohibit a physician from
performing any surgical operation he deems
necessary in the exercise of his professional
skill and judgement. It merely provides that if a
practitioner wishes to be compensated for his
services by the federal government, he is re-
quired to comply with certain guidelines and
procedures enumerated in the statute . . .

"Underlying the constitutionality of the chal-
lenged legislation is the basic premise that each
individual physician and practitioner has the
ability to choose whether or not to participate in
the program. It is true that there will exist
economic incentive or inducement to partici-
pate in the program. However , such inducement
is not tantamount to coercion or duress.

In response to the plaintiff s contention that
the law would interfere with physician-patient
relationship by imposing a system of "norms of

care, diagnosis and treatment’ the court stated,

"given the legislative standard of reasonable-
ness and statutory flexibility to take into ac-
count various methods of treatment, the court
finds no merit to the plaintiff s argument that
the system of norms to be established under the
statutory scheme will unconstitutionally inter-
fere with the physician-patient relationship.

The AAPS also argued that the statutory sec-
tions requiring physicians to furnish informa-
tion concerning their patients violated the con-
stitutional rights of privacy. In response the
court stated that the statutory "procedures are
reasonable in scope in that they contain provi-
sions designed to assure confidentiality.” The
court then went on to quote a decision ir
another federal case that stated, Congress is
simply imposing a condition on the spending o
federal funds.”

Another contention of the AAPS was tha
numerous words and phrases contained in th<
statute were vague and uncertain and that thi
vagueness violated the specificity requirement
of the Fifth Amendment of the Constitution.

The court points out, "the test in determininj

Oklahoma State Medical Associatio

whether or not a statute is unconstitutionally
vague is whether men of common intelligence
must necessarily guess at its meaning.” The
court went on to state, "Congress faced a dif-
ficult task in drafting this statute with suffi-
cient specificity to give the physicians, prac-
titioners and providers of health care service
adequate notice of the new requirements of the
law and at the same time to maintain enough
flexibility to cover a variety of medical cases. In
accomplishing this task Congress did not stray
beyond the permissible boundaries of the con-
stitution.”

Another section of the PSRO law that was
challenged was that which established certain
limitations of liability. The AAPS contended
the Congress lacked the authority to grant legal
immunity against common law port liability
and that if such immunity was unconstitu-
tional, the PSRO law would then impose duties
and obligations on physicians that could uncon-
stitutionally expose them to civil liability.

In responding to this point, the court points
out, "the possibility of exposure to civil liability
sometime in future as a result of complying
with the statutory norms does not amount to
that type of real and immediate threat of injury
which is necessary. . to bring a case into
federal court. Courts have traditionally refused
to hear cases in which there is no real issue.

The statutory requirement that physicians
must provide evidence of their performance of
services was also attacked by AAPS. They con-
tended that the medical license itself carries
certain presumptions of competence, good
moral character, and regularity of motive and
conduct.

The court cited another case in which it was
held that the issuance of a license is only one of
several ways of being followed by various states
to regulate the practice of medicine.

The AAPS also contended that the fact that a
private organization had entered into a contrac-
tual relationship with the Health, Education
and Welfare Department would, per se, bias the
organization against physicians.

The court stated that this argument was ill-
founded and pointed out that PSROs, by stat-
ute, must be non-profit organizations. Member-
1 ship in such a PSRO is open to every physician
in the area, and all review of medical decisions

I would be made by a physician. The court ended

II by saying, "thus, plaintiffs allegation that
1 these private organizations will be biased is
1 totally without merit.”

The court pointed out that the final argument

Journal / June 1975 / Volume 68

being advanced by the AAPS, and buttressed by
a lengthy amicus curiae brief filed by the
Association of Councils of Medical Staffs of Pri-
vate Hospitals, Inc., was a broad attack on the
legislation as an inefficient and unnecessary
interference with their right to practice medi-
cine.

The court commented, "Congress has enacted
this legislation as a vehicle to better control
expenditures of the federal government in con-
nection with the Medicare and Medicaid pro-
grams. In view of the already extensive pres-
ence of the federal government in the health
care sphere, it can hardly be said that a statu-
tory scheme designed to achieve better cost con-
trol in the field of health care is outside the
competency of the federal government.

"The means that Congress has chosen to at-
tain these economic goals are not arbitrary and
totally lacking in rationality. Underlying the
constitutionality of the legislation is the fact
that the program is a voluntary one in which a
physician may freely choose whether or not to
participate. However, should a physician
choose to participate, he must then comply with
these requirements in order to be compensated
for his services.

"This legislation represents the first medical
Utilization Review Program that is national in
scope. In attempting to avoid over-utilization
and to achieve better cost control in the health
care field, the Professional Standards Review
Law comes in close proximity to the rights of
those physicians and other providers of health
care services in the Medicare and Medicaid pro-
grams. Yet there must be a balancing between
those interests and the government interests in
providing and maintaining medical care to
those most in need of it.

"The Professional Standards Review Legisla-
tion properly preserves that balancing of inter-
est. In upholding the constitutionality of the
legislation on its face, this court does not reach
the validity of the statute as it will be applied.
Nor does this court pass upon the wisdom of this
particular piece of legislation. Whether the im-
plementation and application of this statute
may result in an unwieldy bureaucracy of mon-
strous proportions is a policy question for the
consideration of the legislative rather than the
judicial branch of the government.”

The court closed by issuing an order which
stated, ". . . it is hereby ordered that this cause
be dismissed for failure to state a claim upon
which relief can be granted.” □

201

BEVERLY HILLS HOSPITAL
®I VIRL Y HILLS CLINIC

-■ ■- n

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

PSYCHIATRY

Jackson H. Speegle, MD
John T. Holbrook, MD

PSYCHOLOGY

George R. Mount, PhD
Donald L. Whaley, PhD

Tom I. Payton, MS
Patrick R. Barnes, MS

EDUCATION DIRECTOR
William E. Nix, PhD

Fred H. Jordan, MD
Joseph H. Lindsay, MD

DIRECTOR OF NURSES

Nita Ivey, RN

01. AND R.T. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211

214 331-8331

202

Oklahoma State Medical Association

National Malpractice Situation Bad-—
Federal Intervention Could Be Worse

Congress has been told by the American Med-
ical Association that federal legislative re-
medies for the professional liability crisis could
create a worse situation and in some cases re-
sult in even higher liability costs.

In testimony before the Senate Health Sub-
committee headed by Senator Edward Kennedy
(D-Mass.) as it opened hearings on the liability
issue, AMA President Malcolm C. Todd, MD,
declared "it is far wiser for states to enact varied
innovative legislative responses to the problem
than to have an untested and unproved scheme
enacted on a nationwide basis by the federal
government particularly when such proposals
contain elaborate provisions for federal gov-
ernment regulations of the practice of medi-
cine.”

While stating that there is no question that a
crisis exists in medical liability insurance cov-
erage, the AMA president went on to say, "the
complexity of the problem, and its varied causes
convince us, however, there is no single solu-
tion, be it arbitration, 'no fault,’ or anything
else.”

Doctor Todd then pointed out that many
states are acting on the professional liability
problem. "Perhaps the eventual solution in
most states will be a synthesis of various ap-
proaches . . . enactment of a federal program
would eliminate the state’s initiative and would
establish a program that would fail to recognize
individual state problems.”

One of the bills currently pending before the
Health Sub-committee proposes compulsory
arbitration tied to licensure and relicensure of
physicians, review of all physicians’ services by
Professional Standards Review Organizations,
acceptance of federal fee schedules under Medi-
care and required consultation before surgery.
These restrictions "have not demonstrated rela-
tionship to the problems of medical liability or
liability insurance,” the AMA president said.
"Rather the crisis-need for remedies for these
problems is being used as a devise for imposi-
tion of further government medling in the prac-
tice of medicine.”

A surprised Senator Edward Kennedy has
encountered a wall of opposition from the major
groups involved in the medical liability crisis
with the respect of federal intervention as a
solution. The administration has joined the
AMA, the American Hospital Association, and
1 the American Trial Lawyers Association in urg-

ing that the federal government keep out of the
liability picture at least for the time being.

Most of the suggested remedies so far carry
bad news for some group, either increased gov-
ernmental controls on physicians and hospitals,
loss of fee income for lawyers, or some under-
mining of the medical consumers right to sue. In
addition, insurance has always been very much
a state prerogative in the Unites States and
federal legislation that infringes on states’
powers over insurance is always difficult to en-
act.

Washington observers now state that the
likelihood of Congressional action this year on a
broad liability bill appears remote. An under-
current of opinion on Capitol Hill seems to be
that the problem should be faced when a
national health insurance program is
considered. □

Hawaii Tour Filling Fast

Over 200 physicians and their spouses have
signed up for the OSMA sponsored tour to
Hawaii for the 1975 AMA Clinical Session in
Honolulu.

The AMA Clinical will run from November
30th until December 5th. The OSMA tour will
leave for Hawaii on November 28th and return
on December 7th.

The basic tour includes roundtrip jet economy
airfare from Oklahoma City to Honolulu via
Braniffs 747 and all inter-island airfares.
Seven nights of superior room accommodations
will be furnished at the beautiful Hawaii Re-
gent Hotel on Waikiki. The basic tour then in-
cludes two nights superior room accommoda-
tions at the magnificent Maui Surf Hotel on the
Valley Island of Maui. However, there is an
optional tour, costing $51 per person extra, that
is two nights at the Mauna Kea Hotel on the
"big” island of Hawaii.

The basic tour price per person for superior
room accommodations is $575 or $595 for de-
luxe room accommodations, double occupancy.
Both prices include the two days at the Maui
Surf Hotel. The Mauna Kea option adds $51 to
either price.

The tour offers physicians an opportunity to
attend the entire AMA Clinical Session in
Honolulu, and then take a post-convention trip
to Maui. Registration should be directed to the
Oklahoma State Medical Association, Atten-
tion, Don Blair, 601 Northwest Expressway,
Oklahoma City, Oklahoma 73118. □

N Journal / June 1975 / Volume 68

203

Offering complete private Psy-
chiatric Services using the
Therapeutic Community ap-
proach in an open setting.

Fully Aecrediated
60 Beds

Mrs. Billie Speck-Administrator

MEDiCENTER PSYCHIATRIC
HOSPITAL

1505 Eighth Wichita Falls, Texas 76301

Services Available

9 Psychotherapy individual and Group
® Chemotherapy
@ Recreational Therapy
9 Occupational Therapy

• Psychological Testing

® Psychiatric Social Worker Services
9 Neurological Consultation

• Electro-Convulsive Therapy
9 Clinical Laboratory
® X-ray

• Pharmacy
® Physical Therapy
9 Medical Consultations

AMA Introduces New NH1
Proposal in Congress

The American Medical Association has in-
troduced a new proposal for national health in-
surance into the United States Congress. Key
lawmakers on both sides of the aisle in the
House of Representatives are sponsors of the
bill, HR 6222.

The AMA proposal is the only substantially
new approach to national health insurance
(NHI) presented so far in the 94th Congress. It
is called the Comprehensive Health Care In-
surance Act. The bill was authored by two
Democrats and two Republicans: Representa-
tive Richard Fulton, a Democrat from Tennes-
see; John Murphy, a Democrat from New York,
Tim Lee Carter, a Kentucky Republican; and
John Duncan, a Tennessee Republican.

The AMA’s NHI plan builds on the structure
of the present system of employer-employee
group health insurance plans, mandating each
employer to provide comprehensive and ca-
tastrophic benefit coverage with the employer
picking up at least 65% of the cost. Employees
would not be compelled to participate.

The self-employed as well as the non-
employed could purchase qualified private

health insurance, through pools if needed, at a
cost not more than 125 percent of the cost of
group plans. They would have all or part of the
premium paid by the federal government de-
pending upon their income tax liability.

Small businesses that find the mandated plan
an added financial burden could receive federal
assistance.

Medicare beneficiaries could purchase sup-
plemental insurance to bring Medicare benefits
up to a par with those offered elsewhere, with
the government assisting people with limited
resources. Medicaid would be eliminated under
the program.

After a certain level of co-insurance is
reached, depending upon income, insurance
covers all remaining costs as a complete protec-
tion against catastrophic costs.

The co-insurance factor would depend on one
of needed care. The absolute maximum that any
individual would have to pay would be $1,500,
while the absolute maximum for any family
would be $2,000 in any given year.

Representative Fulton, a member of the
House, Ways and Means Committee, told the
House that the bill "represents the evolution of
the doctors thinking on this complex subject;

204

Oklahoma State Medical Association

and it demonstrates that the continuing process
of discussion and debate has influenced the doc-
tors as, indeed it has influenced the thinking of
Congress.”

"We must build on the structure of group
health insurance which is today providing
sound basic coverage for a vast majority of
Americans at no cost to the government,” the
representative said. "It is easier to remedy
whatever deficiencies exist in this mechanism
than to junk it in favor of a new and elaborate
government structure that would have to be
created from scratch ... it would also be con-
siderably less traumatic for Americans to re-
main with a familiar system . . .”

Third ranking Republican on the House,
Ways and Means Committee, Representative
John Duncan, said in a House speech that "the
AMA plan does the best job to date in identify-
ing the line between national bankruptcy and
national parsimony in expenditures for na-
tional health insurance.

"The doctors plan provides federal assistance
on the basis of need. The most help goes to those
who need it most. The least help goes to those
who need it least.”

He went on to say that the Comprehensive
Health Care Insurance Act removes the fear of
catastrophic illness that plagues even well-off
Americans and provides weekly regular be-
nefits, including 365 days of inpatient hospital
care, 100 days of skilled nursing care, full den-
tal care for children, home health benefits and
many other services including psychiatric
treatment and well baby care.

Kentucky’s Representative Tim Lee Carter, a
physician-member of Congress and ranking
minority member of the House Health Sub-
committee, said the bill "retains a large meas-
ure of pluralism in the administration and fi-
nancing . . . and it is precisely this pluralism
. . . the creativity and sensitivity of the private
sector, supplemented only where necessary by
government . . . that has made the quality of
American medicine hands down the finest in
the world.”

Doctor Carter pointed to the cost control
mechanism of "co-insurance” that is applicable
to all, except for the poor, in the physicians’
plan. "There is incontestable evidence that any
health care system without some regulatory
control is soon bogged down by the
'worried-well,’ ” he said.

Representative John Murphy of New York, a
member of the Commerce Committee, said that

organized medicine’s plan "does about what the
federal government can afford to do at this par-
ticular time. It will not be legislation that
over-promises and underperforms.” Murphy
declared, "because the program utilizes the ex-
isting structure of the private insurance indus-
try, there can be a fast startup. There will be
minimum of administrative costs and bureau-
cratic delays.

"This is the place to start: a sound foundation
of comprehensive health services, available to
all Americans, and at a reasonable cost.” □

Professional Liability Guide
Again Available from OSMA

The "Professional Liability Medical-Legal
Guide for Physicians” booklet prepared by the
OSMA is again available upon request to all
physician members of the association. The
booklet discusses important doctrines of law,
gives a series of malpractice preventive meas-
ures that physicians can take, and includes a
number of medical-legal forms to be used.

The booklet was originally prepared by the
OSMA staff in 1969 and was printed by the
Insurance Company of North America and dis-
tributed to all association members. It has now
been republished in quantity and is available
upon request by contacting the Oklahoma State
Medical Association, 601 Northwest Express-
way, Oklahoma City, Oklahoma 73118 or cal-
ling Area Code 405-842-3361.

In the section on Important Doctrines of Law
there is a discussion of battery, consent, in-
formed consent, discreet disclosure, profes-
sional negligence, standards of care, liability
for the acts of others, and the two doctrines
known as "captain of the ship” and "res ipsa
loquitur.”

Another section of the book contains a
number of medical-legal forms, 14 in all. In
addition, it also contains four form letters that
might be of use to a physician: a letter to con-
firm discharge by a patient, a letter of with-
drawal from the case, a letter to the patient who
fails to keep appointments, and a letter to a
patient who fails to follow advice.

In addition to the booklet, speakers on mal-
practice prevention are available from the
OSMA to talk to county medical societies, hos-
pital staff meetings, clinic staff meetings, etc.
Arrangements for these speakers may be made
through the OSMA, Attention Ed Kelsay, As-
sociate Executive Director. □

Journal / June 1975 / Volume 68

205

HEALTH CARE MANAGEMENT

MASSES OF PAPERWORK AND SLOW RECEIVABLES
. . these two enemies are overwhelming todays Medical
Office! How to deal with these two is the “number one
business problem” for many doctors.

in DIRECT RESPONSE to THESE PROBLEMS and
related business needs of the Physician, HCM, with
YEARS of EXPERIENCE in MEDICAL BILLING and
COMPUTER OPERATIONS, has developed a TOTAL
SYSTEM for Physician’s Billing and Accounts
Receivable Management.

ROM’s system is simple, easy to learn, requires no
special equipment, is flexible, and can follow along the
lines of your present business office procedures.

For further information, contact:
Gene Highfil!

Academy Computing Corporation
3535 NW 58th — Suite 102
Oklahoma City, Oklahoma 73112
405/947-7746

SPONSORED BYTHE OSMA

Washington National Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE
DISABILITY INCOME INSURANCE

Contact Association Counselors:

Jim Thaxton, Bill Howard or Rodman A. Prates

Administrators

720 NW 50th

PO Box 1 8593 405 842-3735 Oklahoma City 73118

206

Oklahoma State Medical Association

Alcoholism Treatment Center
In Cushing, Oklahoma

Another Valley Hope Alcoholism Treatment
Center, the third of its kind, was just recently
opened in Cushing, Oklahoma. This center
came about through tireless efforts of a group of
Oklahomans who recognized a need for alco-
holism treatment in Oklahoma as embodied in
the Valley Hope Program. The Cushing Valley
Hope Treatment Center opened on June 3rd,
1974 and since then has been offering hope and
a start toward lasting sobriety to suffering al-
coholics and their families.

From a shoestring start in August, 1967, the
unique program of Valley Hope was conceived
and begun in Norton, Kansas. By August 28th,
Valley Hope had a staff of ten, plus three Norton
physicians and ten patients. Two weeks later
the state licensed it as a qualified psychiatric
unit hospital. More patients followed. Kansas
Blue Cross-Blue Shield then accepted Valley
Hope as a non-member hospital to pay up to 80%
of treatment costs for member patients. This
was a major breakthrough and since then 29
other health insurance companies have ap-
proved Valley Hope Centers.

Purchase of a five-year-old motel in Norton,
Kansas, which would house 68 patients was
accomplished through tireless fund-raising ef-
forts by many dedicated persons. Occupancy of
the new facility took place in November, 1968.
Since this time the Valley Hope Association, a
private, non-profit organization has come to
consist of inpatient centers at Norton and Atch-
ison, Kansas and the new center at Cushing,
Oklahoma. The association also operates outpa-
tient counseling and referral offices at Over-
land Park, Wichita, and Abilene, Kansas.

Doctor Wm. D. Leipold, Clinical Director of
the Valley Hope Association, states: "We treat
the alcoholic as a person, a human being. One of
the first goals is to re-establish their human
dignity, which means we operate on a concept of
trust. There are no locks or bars on windows or
doors. Anyone is free to come or go. The program
spends very little time delving into the past,
digging into the archaeology of why the patient
developed alcoholism. The concentration is on:
'What are you going to do about it now?’ The
patient is shown how he or she must become
responsible for his or her own behavior; is
taught how he or she can grow up and leave the
childish behavior habits of the drinking al-
coholic behind.”

Cushing Valley Hope Alcoholism Treatment
Journal / June 1975 / Volume 68

Center contains fifty-one patient rooms, dining
facilities, large lecture hall, rooms for counselor
offices and therapy groups, and recreational fa-
cilities including a swimming pool. An infor-
mal, relaxed, homelike atmosphere is main-
tained for our patients. This facility is a major
step in Valley Hope’s efforts to continually find
a better . . . more efficient way to deal with the
dread disease of alcoholism.

For more information or for help for yourself
or a loved one regarding alcoholism or related
problems, call or write: Valley Hope, P.O. Box
47, Cushing, Oklahoma 74023. Phone: (918)
225-1736. □

Medicare/Medicaid Allowables
to be Reduced

A ceiling on physicians’ allowable fees under
Medicare and Medicaid is being put in place by
the Bureau of Health Insurance. The ceiling
was mandated by Public Law 92-603, the Social
Security Amendments of 1972.

A portion of that law specified that there was
to be a ceiling on physicians’ fees based on
physicians’ charges for calendar year 1971
plus an increase related to an "economic index.”

The initial regulations, published April 14th,
did not specify exactly what the "economic
index” was to be. Later it was announced that
this would be the "cost-of-living” indexes.

The announcement that physicians’
reimbursements would be tied to the cost-of-liv-
ing index drew immediate and angry responses
from the American Medical Association.

Richard E. Palmer, MD, Chairman of the
AMA Board of Trustees, charged that there was
an "appalling lack of the most elementary and
essential information” about the proposal,
which he termed "another federal attempt to
copout on previous commitments to the elderly
and to shift most of the burden onto the individ-
ual patient and the physician.”

HEW gave 30 days for interested parties to
comment on the proposed regulations published
in the Federal Register Doctor Palmer said,
"we’ve been given just 30 days to respond to a
whole new set of HEW regulations to put a lid
on Medicare reimbursement rates. Since the
proposed regulations relate to a law passed over
two years ago, we think we’re entitled to a
minimum of 60 days to examine them and re-
ply-”

The Board Chairman then went on to point

207

news

out the key parts of the regulations were not
even available and that HEW had not supplied
data that they were using to arrive at "ex-
amples” of how the new regulations might be
applied.

Recent information from Medicare indicates
that the formula published in the register
would allow approximately an 18 percent in-
crease over 1971 charged data. This would
mean that many charges currently being
recognized by Medicare and Medicaid would be
reduced.

L. E. Rader, Director of the Oklahoma
Department of Institutions, Social and
Rehabilitative Services, strongly objected to the
new regulations in a letter to J. B. Cardwell,
Commissioner of Social Security of the Depart-
ment of Health, Education and Welfare. Mr.
Rader stated, "the regulations as proposed
would result in significant, widespread reduc-
tion of allowable charges below the current
allowable charges. On unassigned claims, this
will result in reduced payments to beneficiaries
and could result in a sharp decrease in assign-
ments. Many beneficiaries will be asking why
Medicare is paying lower allowable charges
than previously. For the protection of the bene-
ficiaries, recognition should be taken of the
(Department of HEW, delay in implementation
of this section of Public Law 92-603 and the eco-
nomic index should include an adjustment
factor to insure that in no instance will this re-
sult in a lower allowable charge than was al-
lowed in fiscal 1975.)” Emphasis added.

Mr. Rader also objected to the fact that the
"economic index” as listed in the Federal Regis-
ter was not spelled out in detail. He went on to
say, "because of the extreme importance of this
index, we believe it should, pursuant to the
requirements of the Administrative Procedures
Act, be published in proposed form.” He also
stated, in agreement with the American Medi-
cal Association’s contention, that a minimum of
60 days comment time should be given.

Preliminary figures would indicate that
many fees would be reduced below that being
currently allowed by Medicare. As an example,
an initial office visit with complete diagnostic
history and physical examination would be de-
creased, as would an initial home visit, initial
hospital visit then followup hospital visit for
general practitioners. Internal medicine
specialists would have decreases for an initial

208

office visit with a complete diagnostic and his-
tory on an old patient, an initial office visit with
a complete diagnostic and history on a new pa-
tient, followup office visit, a followup office visit
requiring more than routine work, an initial
home visit, and an initial hospital visit.

Orthopedic surgeons would see a slight in-
crease in the fee for a hip replacement pros-
thesis, but a decrease for an amputation
through the femur.

It is projected there would be far more de-
creases, than increases, in the allowable charge
under the new regulations. □

Doctors and Lawyers to
Have Balkan Adventure

Oklahoma physicians and lawyers will be
taking an exclusive two-week charter holiday
to Eastern Europe and the Balkans. Cities to be
visited include Bucharest, Romania; Istanbul,
Turkey; Dubrovnik, Yugoslavia; with a side
trip available to Kiev, Russia.

Arrangements for the tour were made
through INTRAV, a company that has spent
years developing deluxe personalized vacations
at charter cost savings. The tour is being spon-
sored in Oklahoma by the OSMA and the Okla-
homa Bar Association simultaneously. It will
depart from Oklahoma City on July 23rd, and
the cost, which includes direct flights via char-
tered jets, accommodations at the very finest
hotels, full American breakfasts and gourmet
dinners at a choice of the finest restaurants, is
only $1,128 per person.

The Balkan Adventure is not a tour, in the
traditional sense of the word, it is a nonreg-
imented holiday designed to give the traveler a
maximum amount of free time in each city.
Even though the trip is nonregimented, a travel
director and five hosts are available to assist
travelers in each city. Optional sight seeing
tours are available each day for those persons
wishing to go on them.

The adventure begins when travelers board a
chartered World Airways DC8 jet in Oklahoma
City on July 23rd. The jet features stretchout
extra comfort seating, first class meals, com-
plimentary champagne and cocktails, and di-
rect no-change flight to Bucharest.

Bucharest is Romania’s 500-year-old capitol.
There is always a feeling of anticipation just
knowing you are behind the Iron Curtain, yet
the place is friendly and easygoing.

Oklahoma State Medical Association

This part of Europe was the source of many
superstitions. One of the best known of which is
the vampire. Don’t miss the brooding castle of
Count Dracula in the nearby countryside of
Transylvania.

An optional side trip to Kiev, Russia, is avail-
able from Bucharest.

Second stop on the trip is Istanbul, due to its
frenzy, a remarkable contrast to placid
Bucharest. This is the city of intrigue. Here is
the fabled Blue Mosque of Sultan Ahmed and
Sancta Sophia built by Constantine in 325 A.D.

Night clubs feature belly dancers and Tur-
kish folk dancing. The traditional dish, shish
kabob, should be tried with a glass of good Tur-
kish beer. Optional side trips are available to
Izmir and the ancient ruins of Ephesus.

Last stop on the trip is the calm and ancient
walled city of Dubrovnik, Yugoslavia. Resi-
dents of the city take great pride in their
churches, monestaries, art galleries, museums
and hundreds of apartment houses. For an un-
usual dining experience, how about a dinner in
a Benedictine Abbey on a nearby island?

Reservations for the Balkan Adventure may
be made by contacting the Oklahoma State
Medical Association, 601 Northwest Express-
way, Oklahoma City, Oklahoma 73118. A $100
per person deposit is required. □

MD Prescription Deficiencies
Cause Pharmacists Trouble

Several pharmacies throughout the state
have recently discovered that the state law re-
quiring certain information to appear on pre-
scriptions before they are filled will be strictly
complied with. The Office of the Commissioner
of Narcotics and Dangerous Drugs Control for
Oklahoma has sought District Court Action
against pharmacists for failure to comply with
the requirements dealing with controlled sub-
stances.

In a letter to one such pharmacy Acting
Commissioner Dale Dowdy pointed out that the
records of the pharmacy indicated 35 prescrip-
tions in a six month period had not contained
the patient’s address, 37 did not have the pre-
scribing physician’s DEA number, four did not
have the date of the order, and 25 were either
not signed and/or dated by the pharmacist fill-
ing the order.

All of these irregularities are violations of
both the federal and state laws on dangerous
control substances. Although charges against

the pharmacy were dismissed, the pharmacists
did suffer a loss in that the controlled dangerous
substances seized from his pharmacy were de-
stroyed pursuant to Oklahoma statute.

Many of the deficiencies found in the pre-
scriptions were in information required to be
put on the prescription by the prescribing
physician. One federal narcotic agent com-
mented that most pharmacists are reluctant to
refuse to honor a prescription even though it is
not filled out properly.

The state law requires that prescriptions for
controlled substances must be written with ink,
indelible pencil or typewritten and must be
manually signed by the physician. The pre-
scription can be prepared by a secretary or
agent, but it must be signed by the physician.

The prescription must specify the date of its
issue, the full name and address of the patient,
the name and quantity of the controlled dan-
gerous substance being prscribed, directions for
its use, and the name, address, and DEA num-
ber of the prescribing physician. □

Governor Boren Seeks
Doctors for State

Governor David Boren is actively involved in
a ''selling” campaign to encourage Oklahoma-
educated physicians to stay in the state to prac-
tice or return to the state if they sought post-
graduate education elsewhere.

Letters have gone out to the University of
Oklahoma College of Medicine graduates of the
past five years who are out of state or in the
military urging them to consider some of the
fine communities in Oklahoma who need their
services. He is also writing 1975 graduates urg-
ing them to stay in touch with a free "physician
placement service” so they will be aware of
practice opportunities in Oklahoma although
they may be in residency programs outside the
state.

These efforts by the Governor are being coor-
dinated by the Oklahoma Council for Health
Careers, Inc., a private non-profit corporation
designed to recruit young people into health
careers starting in 1967. They undertook the
task of locating physicians for small Oklahoma
communities whose plight seemed desperate by
developing a matchmaking service. Physicians
complete an application form, and community
leaders answer seven pages of questions about
things doctors might want to know in consid-
ering a particular community.

Journal / June 1975 / Volume 68

209

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance
Springfield, Mass.

For additional details and application form, please contact

Jim Thaxton

Administrator

720 N. W. 50th Telephone 405 848-7661

P.O. Box 18593 Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

£2

DOCTOR, WHAT WILL YOU EARN?

It depends, of course, on your age and annual earninqs, but the amount can quite reasonably
exceed $400,000.

Is this logical? Not when you can participate in the . . .

O.S.M.A. GROUP DISABILITY INCOME PROGRAM

Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION
. . . gives you individual coverage at low group rates.

. . . offers flexible waiting periods at your option.

. . . guarantees you an income when you are disabled from an accident or sickness.

. . . offers optional Indemnity from $200.00 to $2,500.00 per month.

. . . pays for lifetime on accident and up to age 65 on sickness.

For Additional information, call or write

Jim Thaxton, Bill Howard or Rodman A. Prates

C. L. PRATES & COMPANY, INC.

720 N.W„ 50th P.O. Box 18695
OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848-7661

210

Oklahoma State Medical Association

DEATHS

GERALD E. CRONK, MD
1919-1975

Tulsa internist, Gerald E. Cronk,
MD, 55, died April 23rd, 1975. A native
of Tulsa, Doctor Cronk was the brother
of Robert T. Cronk, MD, also a Tulsa
internist. He was graduated from Duke
University School of Medicine in 1944.
Following two years in military ser-
vice, he took his residency at Maryland
General Hospital, Baltimore and the
Veterans Administration Hospital in
Oklahoma City. In 1951 he entered
practice in Enid.

Doctor Cronk was a member of the
American Board of Internal Medicine
and the American College of
Physicians.

EUGENE G. WOLFF, MD
1901-1975

Eugene G. Wolff, MD, retired anes-
thesiologist, Tulsa, died April 12th,
1975. Doctor Wolff received his medical
degree from the University of Okla-
homa College of Medicine in 1934. He
practiced in Tulsa for 30 years before
his retirement in the late 1960s.

Doctor Wolff was a Fellow of the
American College of Anesthesiologists
and a Life Member of the Oklahoma
State Medical Association.

Oklahoma Affiliate
Appointed By ADA

The Greater Oklahoma City Diabetes
Association has been appointed the Oklahoma
Affiliate by the American Diabetes Associa-
tion. This makes responsibilities statewide in-
stead of just areawide.

New offices were opened May 1st and the
proper mailing address is American Diabetes
Association, Oklahoma Affiliate, Suite 146,
2801 N.W. Expressway, Oklahoma City, Okla-
homa 73112, Telephone 405 842-8839. □

DELBERT G. SMITH, MD
1903-1975

Delbert G. Smith, MD, an Oklahoma
City physician since 1930, died May
13th, 1975. In addition to his private
practice, Doctor Smith was Professor
Emeritus and a 33-year Obstetrics Pro-
fessor at the University of Oklahoma
College of Medicine, where he was
graduated in 1929.

A native of Arcadia, Oklahoma, he
was prominent in his medical affil-
iations, having served as President of
the Oklahoma City Chapter of the
OB-GYN Society. He performed the
first Caesarean section on closed circuit
television in 1951. He was a Life Fellow
of the American College of Obste-
tricians; a Life member of the Okla-
homa State Medical Association; and
held memberships in the International
College of Surgeons, the Southern Med-
ical Association, the Central Associa-
tion of Obstetricians and Gynecologists
and the Oklahoma City Clinical Soci-
ety.

RUSSELL W. LEWIS, MD
1906-1975

Sulphur physician, Russell W.
Lewis, MD, 68, died May 4th, 1975. A
native of Drummond, Doctor Lewis was
graduated from the University of
Oklahoma College of Medicine in 1932.
He practiced in Clinton for a while be-
fore moving to Sulphur. □

Social Security “Broke” by 1980

1980 may well see the bankruptcy of the So-
cial Security Administration according to a re-
cent report in the newsletter of the Insurance
Economic Society of America. The report stated
that actuaries for SSA report that unemploy-
ment and inflation are throwing the retirement
system into deficit sooner than forcast.

The deficit is causing outlays to exceed re-
ceipts this year by $2.5 billion, leaving reserves
at $43.4 billion, and by 1980 only $800 million
will be left in reserves. □

211

ama brings continuing

medical education
(C.M.E.) to you

• Near your hometown Recognition Award, and credit for other

• Clinical topics from practicing medicine continuing education programs

• 12 hours of Category I Continuing Medical • Presented on weekends — will not interfere
Education credit toward the AMA’s Physician’s with office hours

Each Regional meeting, sponsored by AMA’s Council on Scientific Assembly, will consist of

eight postgraduate courses:*

1. Human Sexuality 6. Infectious Diseases and Antibiotics

2. Venereal Disease 7. Dermatology for Non-Dermatologists

3. Basic Electrocardiography 8. Basic and Advanced Life Support —

4. Pulmonary Function and Blood Gases Cardiopulmonary Resuscitation (CPR)

5. Fluid and Electrolyte Balance

'Courses 1 through 7 are 6 hours each; each is presented twice

(once on Saturday, once on Sunday), Course No. 8 is a 12-hour course that runs both days.

Sites

Minneapolis, Minn. - July 26-27, 1975
Williamsburg, Va. - September 27-28, 1975

For more information WRITE:

Dept, of Circulation & Records/AMA, 535 N. Dearborn St./ Chicago, IL 60610
CALL (312) 751-6187 for immediate details by return mail

July
1975
68, No.

of the Oklahoma State Medical Association

EDITORIAL BOARD

MARK R. JOHNSON, MD
Editor-in-Chief

CONTENTS

HARRIS D. RILEY, Jr., MD
Editor

ROBERT G. TOMPKINS, MD
Editor

ERNEST LACHMAN, MD
Corresponding Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

editorial

Letters From The Editor: II ... 213

President’s Page ....... 214

scientific

Yesteryears’ Diagnosis, Ed L. Calhoon, MD . . 215

OFFICERS

ARNOLD G. NELSON, MD
President

WILLIAM M. LEEBRON, MD
Vice-President

HAVEN W. MANKIN, MD
Secretary- T reasu rer

special

Famous Scientific Hoaxes, Part I, The Piltdown

Hoax, Ernest Lachman, MD .... 217

Full Employment Opportunity: Does It Exist for the

Handicapped? Cindy Miller .... 225

News .......... 227

STAFF

DON BLAIR
BusinessManager

LOUISE MARTIN
EditorialAssistant

SUBSCRIPTION TO THE JOURNAL is included in
membership fees. Other subscriptions are
$6.50 per year or $1.00 per copy with each
request subject to approval of the Editorial
Board.

news

OSMA Public Relations Program Underway . 228

Weinberger Responds to Nelson Letter . . 231

Putnam City High School Teacher Receives OSMA

Award ........ 232

Life Certificates Awarded Three Tulsa Physi-
cians ......... 232

Proceedings of the 69th Annual Session of the House
of Delegates of the Oklahoma State Medical As-
sociation ........ 233

Nelson Names Councils and Committees . . 235

Arkansas-Oklahoma Cancer Forum Will Convene in

September ........ 238

Death 239

Oklahoma Physicians Tagged For Neurosurgical So-
ciety Offices ....... 239

Miscellaneous Advertisements ..... 241

Index To Advertisers ...... xxii

(Cover Art By William Cason)

POSTMASTERS: Send all change of address
notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

Ill

One contains aspirin.
One doesn’t.

Darvocet-N 100

100 mg. propoxyphene napsylate
and 650 mg. acetaminophen

Darvon

Compound-65

65 mg. propoxyphene hydrochloride,
227 mg. aspirin, 162 mg. phenacetin,
and 32.4 mg. caffeine

Additional information available to the profession on request.
Eli Lilly and Company, Inc., Indianapolis, Indiana 46206

500341

Oklahoma State Medical Association

editorial

LETTERS FROM THE EDITOR; II

Mr. John Public
Hometown, USA

I deeply regret that I was unable to obtain
hospitalization for you following your most re-
cent office visit. As you know, I was — and I
remain — convinced that your illness can best
be treated only in the hospital. I can accept no
alternative plan of treatment without, in my
professional judgment, jeopardizing your
health.

Although I completed all the necessary
forms and satisfied all the government re-
quirements relating to your hospitalization,
the Pre-Admission Utilization Review Com-
mittee (PAURC) disagreed with my con-
clusions and denied your admission to Com-
munity Hospital. The Chairperson of the com-
mittee, in a personal telephone conversation
this afternoon, assured me that your case had
been carefully and thoroughly reviewed by the
expert members of the committee, that the ma-
jority of them favored denial of my request and,
as a final remark, reminded me that if I ig-
nored the decision of the committee and suc-
ceeded in placing you in the hospital in spite of
it, none of your tax-supported "health insur-
ance" would pay for your care. When I told
him/her/it that you had adequate "private in-
surance,” he/she/it replied that none of the so-
called private insurance policies would provide
remuneration for hospital expenses or physi-
cians’ fees unless the hospitalization had been
sanctioned by the PAURC.

You will recall, Mr. Public, that you refused
to enter the hospital unless your "insurance”
paid its stipulated share of the costs as you had
no savings and were unwilling to burden your
wife and children with such a debt. Thus, I

Journal / July 1975 / Volume 68

have no choice but to advise you that I must
resign my role as your physician and suggest
that you immediately select another doctor to
manage your case. Since the Chairperson of
the PAURC implied that the members of the
committee believed that some alternative to
hospital-care was appropriate, and since I can
accept no alternative, I am suggesting that you
contact the Chairperson for his/her/its recom-
mendations concerning your future care.

I suppose, Mr. Public, that we can consider
my resignation from your case as an involun-
tary referral to an uninvited consultant. I
would feel a bit better about the whole affair if
I were acquainted with our consultant — or if I
had any information about his credentials.
However, since he is paid by our government,
and was appointed to such a powerful and re-
sponsible position by our government, I am
certain that he has your best interests at heart
and that he is a competent and unusually tal-
ented person.

In closing, I wish to thank you for selecting
me as your physician during these past twelve
years. I will miss having you as my patient and
I sincerely hope our personal friendship will
continue. Also, I want to thank you again for
the countless hours and dollars you have given
to Community Hospital, especially during the
fifteen years you served as a member of its
Board of Trustees.

Please accept my very best wishes for your
continued good health. If I can be of any service
to you or your new physician, please feel free to
contact me.

Very cordially,
Mark R. Johnson, M. D.
P.S. Perhaps I should advise you that the
members of the PAURC are not, by law, li-
able for any of their "official” actions. MRJ

213

president's page

AMA Annual Assembly, 1975

The 124th Annual Meet-
ing of the American Medi-
cal Association, held in
Atlantic City, New Jersey,
is now history. While the sci-
entific portion of the meet-
ing covered a good cross
section of medicine, and
the scientific sessions were
well attended, the primary
subjects of discussion were professional liability in-
surance for physicians, newer scientific endeavors,
and a dues increase to meet the increasing financial
demands of the association.

The AMA is undergoing the most radical changes
in the history of medicine. Such words and phrases
as "collective bargaining,” "unionism,” "new mili-
tants,” "aggressiveness,” and "strike,” are now com-
ing into common usage. Just two years ago these
words would have horrified our association’s lead-
ers. These words have evolved in our fight for con-
tinued freedom for our patients as well as ourselves.

During recent months many indiscriminate fed-
eral regulations have been written and published.
Physicians are becoming increasingly alarmed at
the number and severity of these regulations, for
many of them not only adversely affect the quality of
medical care, but also withdraw financial assistance
to the poor and elderly. Examples include the
Utilization Review Regulations of late 1974, the
mental retardation housing regulations, and the up-
coming rollback of Medicare reimbursements under
Section 224 of Public Law 92-603.

All of these examples represent financial cutbacks
in federal funds that have been promised to the poor,
the elderly and the disabled. Many of these cutbacks
result from regulations that were not written by
elected leaders, but by federal bureaucrats in Wash-
ington.

The House of Delegates of the AMA approved the
Board of Trustees recommendation to increase an-
nual dues to $250. Our Oklahoma AMA Delegates
fought for a more modest dues increase. It is my
opinion that the reason the dues increase did go
through is that the AMA Board of Trustees has
demonstrated a much more responsible and respon-
sive attitude.

In the future we can expect the AMA to be more
aggressive in fighting our battles. They have al-
ready demonstrated their ability with the federal
court attack on the utilization review problem. Dur-

ing the debate on the floor of the House of Delegates
the leadership was warned time and time again that
the membership would expect the increased dues to
be spent responsibly. It is anticipated that many
more of the indiscriminate federal regulations com-
ing out of HEW will be tested in the courtroom if
necessary.

Many of these regulations are being challenged at
the local level in Oklahoma by the OSMA’s Public
Policy Council. I would encourage you to send your
$100 contribution to the OSMA for this battle. Doc-
tor Joe Crosthwait is chairing this important council
and is devoting many hours to it each week. Please
read the report of the Public Policy Council ac-
tivities on page 228 of this publication.

In regard to malpractice, we in Oklahoma are in-
deed fortunate to have our professional liability in-
surance with the Insurance Company of North
America, INA. Our insurance rates remain among
the lowest in the United States. Number of claims
filed against physicians remains low and, conse-
quently, the losses are low.

Many times I am asked why we have it so good in
Oklahoma. There are several reasons for this. First
and foremost, it just seems to be a way of life in
Oklahoma for people to trust people. Second, I be-
lieve our juries in Oklahoma are fair. Third, the
physicians are well-trained and we have an ongoing
physician educational process that helps prevent
lawsuits.

We do have a distressful professional liability in-
surance problem attempting to force its way into
Oklahoma, however. One insurance company is at-
tempting to place a different type of liability insur-
ance on the market. This is known as a "claims
made” type policy. The "claims made” policy only
renders coverage while the policy is in effect.

The deteriorating professional liability insurance
situation nationally, and the AMA’s battle to do
something about it, reinforces my belief that AMA
membership is now more important than ever be-
fore.

With the new members that the AMA House of
Delegates elected to its Board of Trustees, it would
appear that our national headquarters would be
more responsive than ever before. I believe the in-
vestment of $250 per year in AMA will be the very
best investment ever. I think every physician in this
country should be a member of AMA and pay his or
her own fair share for security to practice medicine
without governmental or other third party interfer-
ence.

214

Oklahoma State Medical Association

Joi

scientific

JOHN

Yesteryears’ Diagnosis

ED L. CALHOON, MD

Acceptable diagnosis and excellence
of the same have evolved ofttimes
as slowly as the truth they bring.

Laws 1961 — page 604 SB No. 81 enacting
sections 931-955 concerning unexplained
deaths became law on January 2, 1962. The
above statute was in no small sense the result
of capable, energetic and keen acumen on the
part of a young physician in Tulsa, Dean Hyde,
MD. This young G.P. refused to sign a death
certificate without autopsy and thus uncovered
the arsenic poisoning death of one Sam Doss by
his wife Nannie Doss. Further investigation
led to the disinterring of previous husband,
nieces and nephew whose remains were all
laced with arsenic. Some twelve of these were
disinterred and many more deaths suspect.

The Nannie Doss case gave needed impetus
to the archaic Coroner’s Inquest and led to sci-
entific investigation of all unexplained deaths
as outlined in the law.

Time evolves many things, but few decisions
in medicine have been more important to
Oklahoma than Medical Examiner’s Laws.
True to their day, many astute physicians

Journal / July 1975 / Volume 68

without benefit of sophisticated laboratory
techniques did, indeed, predict with accuracy
and exactness the true cause of death. Others
remote from medical centers without recourse
to any updating literature were little better
than calculated guesses. World Wars I and II
brought into sharp focus the value of autopsy
and clinical correlation of many diseases which
had previously not been understood, nor their
pathology evident.

Oklahoma’s physicians have been fortunate
in having a basic and ever changing and updat-
ing of diagnosis of disease and its relation to
death. The Medical Examiner’s laws have
caused many physicians to give more than idle
thought when presented with a death certifi-
cate. Though "Natural Causes” is still an ac-
ceptable diagnosis of cause of death, today’s
physicians are ever more aware of necessity of
accurate diagnosis and the far reaching conse-
quence of the failure to report exactness of
deaths. Yesteryears’ certificates contain many

A 1951 graduate of the University of Okla-
homa College of Medicine, Ed L. Calhoon, MD,
is a general surgeon in Beaver, Oklahoma. He is
a Preceptor at the University of Oklahoma
Health Sciences Center. He served as President
of the Oklahoma State Medical Association in
1970-71 and is presently a Delegate to the
American Medical Association. He is a member
of the Rural Health Council of the AM A.

215

Diagnosis / CALHOON

humorous, yet pathetic, diagnoses. Search of
several funeral home records has yielded some
of the more popular diagnoses on death certifi-
cates. For children, 'Cholera Infantum’ and
"Cholera Morbus” was a favorite diagnosis.
And the diagnoses for children did not run the
gamut of absurdity as did other diagnoses on
adult certificates. In no case had autopsy been
done nor tissue exam made (CA of Duodenum
— very rare, autopsy necessary for Dx). Below
are a few of the diagnoses, note the spelling in
certain cases:

1) Heart Cramp, 2) Dislocation of the Heart,
3) Sudden Death, 4) Reflex Action of Nerves
following Stomach Complaint, 5) Accidental
Injury, 6) Dragged by Tractor, 7) Chronic
Diarrhea, 8) General Breakdown, 9) Killed in
Runaway, 10) Cancer of the Duodenum, 11)
Auto Intoxication, 12) Broken neck caused by
falling while having a fit, 13) Liver Complaint,
14) Vertigo, 15) Heart Trouble, 16) Gangrene
following miscarriage, 17) Inflammation of the
Brain, 18) Old age, 19) Stomach Trouble, 20)
Indigestion, 21) Flux, 22) Not Known, 23)
Stoke’s Disease, 24) Acute Mania, 25) Dysen-
tery, 26) Paralysis of the Heart, 27) Granolia,

28) Paralisis, 29) Loss of Red Corpuscles, 30)
Inflammation of the Bowels, 31) General
Paresis of the Insane, 32) Hydropericarditis,
33) Measles and Asma, 34) Injury in Runaway,
35) Congestion of the Bowel. Another popular
cause of infant death which of course was ac-
ceptable, was "Overlain.”

Contemplating the above diagnoses, one is
touched by the lack of scientific thinking, and
yet these were acceptable diagnoses of the
time.

In discussing death and the cause of death,
doing an autopsy per se just for the record, I
feel is perhaps an unnecessary procedure when
one ponders the natural course of certain well
documented diseases and the inevitable conse-
quence of the same. I think perhaps autopsy is
over done and the Medicare and Hospital zeal
for autopsy is not necessary. This article was
written in hopes it would bring to the attention
of the Medical Examiner and the physicians
interesting diagnoses that were encountered in
the past and make us more aware of
Medicolegal problems we now face in the offi-
cial documentation of death. □

REFERENCE

1. Oklahoma Statutes, Public Health and Safety, 1962, 3868-3871.

OSMA Publications Available

PROFESSIONAL LIABILITY MEDICAL-
LEGAL GUIDE FOR PHYSICIANS: This is a
36-page booklet written to assist physicians in
preventing medical malpractice difficulties.

DRUG ^ABUSE TREATMENT MANUAL:
Prepared by the OSMA Alcoholism and Drug
Committee to assist physicians in handling, on
a short-term basis, drug involved patients.

MEDICAL-LEGAL INTERPROFESSION-
AL CODE: This is the standards of coopera-
tion between physicians and attorneys that
have been mutually adopted by the OSMA
and the Oklahoma Bar Association.

All of the above materials may be ordered by
OSMA members free of charge □

216

Oklahoma State Medical Association

Famous Scientific Hoaxes

Part 1. The Piltdown Hoax

ERNEST LACHMAN, MD

The Piltdown affair is one of the greatest
scientific hoaxes in history and involves one to
five scientists whose participation remains an

unsolved mystery.

A recent editorial in this Journal , entitled
"A Biomedical Watergate” called attention to
an apparently faked series of experiments
which seemed to indicate that in transplanta-
tion experiments the rejection of grafts could
be avoided if the transplants, such as skin,
cornea, or adrenal gland could be maintained
in tissue culture for a period of 10 days. Several
scientists were unable to confirm these results
or withdrew from the work in frustration and
disappointment. In 1974 the denouement fi-
nally came when the perpetrator of this hoax
was proved to have darkened the skin of two
white mice with a felt-tipped pencil in the
areas where the animals had been grafted with
skin from black mice. Other experiments by
the same researcher, particularly on corneal
transplants, likewise proved to be based on de-
ception.

There are almost as many motivations for
perpetrating such scientific hoaxes as there are
scientists or pseudo-scientists committing
them and generalizations as to the subjective
reasons of the culprits are best avoided. The
importance of these deceptive fabrications
makes it worthwhile to look at some outstand-
ing bioscientific hoaxes which have influenced
and misled prominent scientists in the pur-
suit of their research. Tremendous energy had
to be expended to uncover the frauds. The re-
sults of the discovery of these hoaxes are often
quite inconclusive and while there remains no
doubt that a deception has been committed, it
is frequently not clear who perpetrated the
fraud and for what reasons.

In its definition of hoaxes, Webster’s Un-
abridged Third Edition lists the Piltdown
forgery as "one of the biggest hoaxes ever
launched on the scientific world.” This fabrica-
tion led to one of the most famous bioscientific
controversies in history and absorbed the
working energy of many outstanding paleon-
tologists and anthropologists of this period.
The whole Piltdown affair represents a tragi-
comedy which comprises an accumulation of
unbelievable human errors and deceptions.
The details of these have been presented in two
books and several hundred articles and chap-
ters in books and can be reported here only in
compressed form. The main sources of this nar-
rative are given in the bibliography.

Journal / July 1975 / Volume 68

217

Hoaxes / LACHMAN

The event centers around Charles Dawson, a
solicitor and antiquarian, who at the time of
the Piltdown discovery already had made a
name for himself as an amateur paleontologist,
and gradually involved most of the prominent
anthropologists of Europe and many scientists
in this country. In December 1912, at a meet-
ing attended by many British geologists, Daw-
son presented to the public his sensational find
of fragments of a remarkably thick human
skull cap and the right half of an ape-like
mandible with two molars. According to Daw-
son the finds were made over a period of four
years in a gravel pit on Piltdown Commons in
Sussex. Later two human nasal bones and
fragments of a turbinate bone were recovered
with the assistance of the distinguished French
archaeologist, Father Teilhard de Chardin,
and the active support of Sir Arthur Smith
Woodward, an eminent paleontologist at the
British Museum in London of impeccable
reputation. All these skeletal remains repre-
sent Piltdown man I, or "Eoanthropus Daw-
soni.” After Dawson’s death in 1916, Wood-
ward supplemented these findings by pieces of
a second human skull and a molar tooth, which
originated in the same geographic area and
represented the so-called Piltdown II skull.
From petrified remains of extinct animals such
as elephants and mastodons and primitive flint
implements from the same gravel pit the find
could be dated as originating in the early
Pleistocene epoch. As such they were at least
half a million years old as compared to the
100,000 years old Neanderthal man. After re-
construction from the fragments, the findings
evolved as "Piltdown or dawn man,” or 'The
earliest Englishman,” as his proponents called
him. He had an astonishingly human cranial
vault with steep forehead of modern man and
hardly any brow ridges, but displayed the
lower jaw of an ape. This combination seemed

Doctor Lachman is Regents Professor
Emeritus of Anatomical and Radiological Sci-
ences at the University of Oklahoma College of
Medicine and Corresponding Editor of the
Journal of the Oklahoma State Medical
Association. Doctor Lachman came to the Uni-
versity of Oklahoma Health Sciences Center in
1934. He received his undergraduate and post-
graduate medical education in Germany and
Scotland.

218

to represent Darwin’s missing link in the chain
between ape and man and apparently gave in-
disputable proof of man’s ape-like ancestors.
Thus, a new evolutionary theory of man’s
origin had apparently been uncovered as com-
pared to the pre-human fossil remains from
South Africa, Java, Peking, and Neanderthal
which were characterized by a simian-type
skull with a low forehead and very prominent
brow ridges and a more human-like jaw, chin
and teeth. In contrast the Piltdown man dis-
played just the reverse features: a human-type
braincase and an ape-like jaw. These two lines
were irreconcilable and no common ancestor
for the diverging lines could be envisaged
(Weiner). The conflict evoked a controversy
that is unequaled in the history of paleontology
and raged for more than 40 years. The combat-
ants could be divided into monists, who con-
tended that skull and jaw belonged to the same
individual, and dualists who rejected the
theory that cranium and jaw were part of one
skeleton and contended that the cranial vault
was that of a fossil, yet rather modern type of
man, but that the jaw belonged to an anthro-
poid ape. They asserted that their association
in the same gravel pit was purely accidental.
To the monistic group belonged — in addition
to Woodward — the famous Australian paleon-
tologist Sir Grafton Elliot Smith, Teilhard de
Chardin, and Sir Arthur Keith, the curator of 1
the Museum and Hunterian Professor of the
Royal College of Surgeons of England and one
time President of the Royal Anthropological
Institute of Great Britain and author of num-
erous scientific works. Keith as the most vocal
advocate of "Eoanthropus Dawsoni” asserted
that Piltdown man originated much earlier
than Neanderthal man, yet showed many more
modern characteristics than the latter. Accord-
ing to him the discovery of Dawson and Wood-
ward was of greater importance than the
originators were aware of. In contrast to their
more modest claims, Keith stated that they
had found Pliocene man, not Pleistocene man,
which expressed a difference in age of more
than one million years. He further insisted
that the volume of Piltdown man’s brain was
as large as that of modern man.

The dualists were mostly American and
German, among them the famous anatomist
and paleontologist, Weidenreich. They identi-
fied the jaw as that of a chimpanzee or orangu-
tan.

In order not to lose our perspective, we
should recognize that throughout this period of

Oklahoma State Medical Association

controversy Piltdown man as a concept was far
from being universally accepted, particularly
in the later years of the debate. A third group
not pretending to know the answer to the
puzzling data suggested that the Piltdown find
be put aside or ignored until additional evi-
dence became available, an evasive response to
the problem that did not contribute to its solu-
tion.

Charles Dawson, Piltdown man’s discoverer,
acquired widespread fame and only his early
death in 1916 deprived him of a knighthood
and a royal pension. Twenty years later his
accomplishments were commemorated by the
erection of a memorial stone at the site of his
finds. On that occasion, Sir Arthur Keith gave
an eloquent oration to a large audience, in
which he celebrated the tremendous achieve-
ment of an amateur paleontologist and com-
pared his accomplishment to the discovery of
Neanderthal man.

Forty years later in November 1953, came
the denouement with the announcement by
three famous British anthropologists from the
Department of Anatomy at Oxford in coopera-
tion with the Department of Geology at the
British Museum, that Piltdown man was a
fraud. They demonstrated quite clearly that
the mandible and canine tooth are those of a
modern large ape which had been skillfully
doctored by filing, abrasion, and chemical
staining to simulate the fossilized material of
the skull cap. The scientists proved without
doubt that the cranial fragments, except for
their thickness, represent a modern type of
human calvarium which in no way differs
from other fossilized human bones found
elsewhere. It was probably not more than
600-700 years old (Kenneth Oakley). It was
furthermore shown by sophisticated meth-
3 ods that the fossilized bones of extinct animals
found with the human fragments did not orig-
inate in Britain, but were imported, probably
from a site in Tunisia and that the tools, such
: as fossilized elephant bones, had been worked
] over with modern instruments and the flint
; stones had been superficially colored with
chromate and iron stains,
dj Thus, the Piltdown hoax which seemed to in-
;t troduce such an insoluble riddle of a freakish
i- human-like being with "a modern thinker’s
i- forehead and jutting simian jaws” and which
had puzzled and embarrassed scientists for
e more than 40 years, had finally been exposed,
jf Nothing remained but the fact that many out-

N Journal / July 1975 / Volume 68

standing scientists of this era had been duped
by an unscrupulous fraud "that finds no paral-
lel in the history of paleontological discovery”.

There remains the question: what kind of
man did commit this hoax? He must have been
an individual that combined profound know-
ledge of anatomy, paleontology and geology
with outstanding technical skill. Was Dawson,
who seemed the most likely suspect at the time
of the uncovery of the fraud, such a person?
Authorities of the period seemed to think so. J.
S. Weiner, who as one of the three British
scientists so actively participated in the de-
nouement of the hoax, seemed to think so in his
book The Piltdown Forgery which appeared in
1955. But, as he concedes, there is no positive
and final proof of Dawson’s guilt. Weiner hints
that Dawson might have thought of his under-
taking as a "joke” that got out of hand, but he
was not an "anti-Darwinist” or anti-evolution-
ist who might have gone through a good deal of
trouble to compromise the theory of evolution.
In a more recent book published in 1972, the
author, Ronald Millar, regards — in addition
to Dawson — at least four other men, all well-
known scientists, as possible participators in
the deception. Like others before him he states
that Piltdown man was a hoax that went sour.
According to him the deception was certainly
not intended as a forgery that could stand the
test of time. He actually finds one of the par-
ticipating researchers more suspect than Daw-
son.

The Piltdown hoax was a tremendous waste
of time, energy, and brainpower that confused
the authorities for many years and retarded
the progress of science. If anything can be
learned from the affair, it is that in the future
scientists will have to be more skeptical in ac-
cepting surprising data and theories. In dis-
proving the existence of Piltdown man, fluor-
ine, nitrogen and uranium assay techniques
could have been applied considerably earlier.
Some of the involved scientists even worked
only from plaster casts instead of the actual
bones. Today, carbon (C- 14) or the recently in-
troduced potassium-argon dating would have
easily uncovered the fraud. The most likely
motive for the perpetration of this deception
must have been a tongue-in-cheek or "smarter
than thou” approach on the part of the culprit
or culprits. Webster’s older definition of a hoax
(in the Second Unabridged Edition) seems to fit
the case perfectly: "A deception for mockery or
mischief; a deceptive trick; a practical joke.” In

219

Hoaxes / LACHMAN

our case it was a practical joke of monumental
dimensions.

In closing, however, one must concede with
Weiner, "that there is no doubt about the real-
ity of transformation which has brought Man
from his simian status to his sapiens form and
capability.” LJ

REFERENCES

1. Beck, W. S.: Modern Science and the Nature of Life, pp. 127-129. Double-
day and Company, Inc!, Anchor Book, New York, 1961.

2. Howells, W.: Mankind in the Making, Chapter 17, pp. 243-257. Doubleday
and Company, Inc., New York, 1959.

3. Keith, Arthur: The Antiquity of Man, Chapters 18-28, pp. 293-511. J. B.
Lippincott Company, London, 1915.

4. Lachman, E.: A biomedical "Watergate.” J. Okla. St. Med. Assn., 67:
427-428, 1974.

5. LeGros Clark, W. E.: The Fossil Evidence for Human Evolution, p. 80.
University of Chicago Press, Chicago, 1955.

6. MacDougall, Curtis D ..Hoaxes. Second Edition, Dover Publications, Inc.,
New York, 1958.

7. Millar, R.: The Piltdown Men. St. Martin’s Press, New York, 1972.

8. Moore, K.: Man, Time, and Fossils. The Story of Evolution, pp. 341-390.
Alfred E. Knopf, New York, 1953.

9. Straus, W L., Jr.: The great Piltdown hoax. Science, 1 19: 265-269, 1954.

10. Weiner, J. L.: The Piltdown Forgery. Oxford University Press, London,
New York, Toronto, 1955.

11. Wendt, H : In Search of Adam, pp. 448-461. Collier Books, New York,
1963.

NOW AVAILABLE

PROFESSIONAL LIABILITY

MEDICAL — LEGAL GUIDE FOR PHYSICIANS

PUBLISHED BY

OKLAHOMA STATE MEDICAL ASSOCIATION

This booklet was prepared by the staff of the
OSMA in 1969 and was published by the Insur-
ance Company of North America for distribu-
tion to all medical doctors in the state. It has
now been republished and is available upon re-
quest.

Requests for the book should be directed to
the Oklahoma State Medical Association, 601
Northwest Expressway, Oklahoma City, Okla-
homa 73118.

There is no charge for this booklet.

Indications: Pro-Banthlne is effective as
adjunctive therapy in the treatment of peptic
ulcer. Dosage must be adjusted to the
individual.

Warnings: Patients with severe cardiac
disease should be given this medication
with caution. Fever and possibly heat stroke
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Overdosage may cause a curare-like action,
with loss of voluntary muscle control.

For such patients prompt and continuing
artificial respiration should be applied until
the drug effect has been exhausted.

Overdosage should be avoided in patients
severely ill with ulcerative colitis.

How Supplied: Pro-BanthTne is supplied as
tablets of 15 and 7.5 mg., as prolonged-
acting tablets of 30 mg. and, for parenteral
use, as serum-type vials of 30 mg.

Searle & Co.

San Juan, Puerto Rico 00936

Address medical inquiries to: G. D. Searle & Co.

Medical Department, Box 5110, Chicago, III. 60680 481

SEARLE

220

Oklahoma State Medical Association

Full Employment Opportunity:
Does It Exist for the Handicapped?

CINDY MILLER

This is the first place winning essay in the
rr Ability Counts” contest which is sponsored by
the Governor s Committee of Employment of
the Handicapped. The OSMA contributes a
$250 expense-paid trip to Washington, DC, for
the teacher of the first-place winner. The au-
thor, Cindy Miller is a student at Putnam

City High School.

A caterpillar spins a cocoon around himself
and hides within it. The cocoon hangs lifeless
among the green-colored leaves, almost hidden
and unnoticed. Finally, after a long wait, the
cocoon splits, and from it emerges a butterfly,
eager to begin life again.

A handicapped person, like the caterpillar,
builds a cocoon around himself and hides in-
side. He becomes lifeless and unnoticed, sepa-
rated from the green leaves of society. The
handicapped people need to be given the
chance to break open their cocoons and begin
life again. Full opportunity employment can
give them this chance.

Jerry Cook was given her opportunity. She
broke her cocoon wide open when she began
work at Hughes Aircraft Company. She works
as an accountant, and even though she has

only one arm, she types 45 words per minute.
When she is not working, Jerry is teaching her
copyrighted typing system to similarly handi-
capped people in the ghetto.1

Harry Rath was not so fortunate. With one
leg missing at the knee, he applied for the job
he had been experienced in before his disabling
injury — that of truck driver. Despite evidence
that men with one leg can perform truck driver
duties with skill and safety, Harry was. turned
down. The trucking company manager felt cus-
tomers would object to entrusting their goods
to a one-legged driver. Instead of breaking out
of his cocoon, Harry Rath just curled up inside
of it.2

The handicapped are people who are fully
capable of work despite their mental or physi-
cal disabilities. They are willing workers, but
are often deprived of their opportunity by mis-
understanding and bias.

There is much more unemployment among
the handicapped than there should be. One
reason is that they need more training and
preparation for a job. Another reason is that
many have just given up hope of finding a job.
Some have become so discouraged that they
have dropped from the labor market and are
not even counted among the unemployed any
more. The main reason, however, is America’s
attitude toward the handicapped and its accep-
tance of them. To illustrate just how much ac-
ceptance the handicapped people do have, the
Roper Research Associates surveyed one
thousand adults across the Nation. The people

Journal / July 1975 / Volume 68

225

Opportunity / MILLER

surveyed were shown three case histories, the
first concerning a mildly retarded young man,
the second a blind youth, and the third a young
man crippled by a birth defect. The people were
then asked what should be done about them.
Half the people favored institutionalizing the
retarded man. Over one-third favored institu-
tionalizing the blind man, and over one-fifth
gave the same response for the crippled man.
Fifty-eight percent of the people thought shel-
tered employment should be allowed for the re-
tarded man. Forty-five percent favored shel-
tered employment for the blind man, and
thirty-nine percent for the crippled man. Only
sixteen percent believed the retarded man
should be permitted to work with others at a
regular job. Forty-four percent favored this for
the blind man, and thirty-six for the crippled
man.3

Throughout all these answers lies one word:
rejection. Just as people turn away from the
sight of a caterpillar, they also turn away from
the handicapped. America does not understand
the handicapped. Every unemployed hand-
icapped represents dashed hopes, despair, dis-
couragement, frustration. For years, these
people have been denied jobs because of mis-
understanding, but America is finally begin-
ning to wake up to their abilities and useful-
ness.

The trends toward automation and speciali-
zation in industry today are opening up new
working fields for the handicapped. A highly

trained computer engineer, for example, per-
forms his vital job perfectly well at Hughes
Aircraft Company, though he has been almost
totally paralyzed by polio for five years.4

A large Chicago insurance company has
found that deaf mutes make better-than-aver-
age file clerks and checkers. They are able to
concentrate better because they are not af-
fected by office noise and distractions. Other
deaf people have learned to work as linotype,
tabulator, and key-punch operators. Blind
workers, with their sense of touch highly de-
veloped because of their loss of sight, have
made superior assemblers, inspectors, sorters,
and counters of small objects in such vital in-
dustries as electronics and aircraft and missile
production. Even cerebral palsy victims have
been trained to use precise hand tools and work
productively on assembly lines.5

These new fields are giving handicapped
people a chance to prove to themselves and to
America that they can do it. They have always
been willing to break out of their almost un-
bearable cocoon. Given the opportunity of full
employment, the handicapped, too, can emerge
from their cocoon and become beautiful but-
terflies in today’s society. □

REFERENCES

1. Harold Russell, "Government, Industry Help the Handicapped,” Reprint
from NAM Reports, Vol. 15, Nov. 23, 1970, p. 47.

2. Lawrence N. Loban, "The Problem of Imposed Handicap,” Reprint from
Personal Journal, Vol. 47, May 1968, p. 5.

3 In Our Path. (Washington, D.C.: President’s Committee on Employment of
the Handicapped, 1972-73), p. 3.

4. Hiring the Handicapped: Facts and Myths, (Chicago: American Mutual
Insurance Alliance), p. e.

5. Ibid., p. 3.

SEVENTH ANNUAL ARKANSAS-OKLAHOMA CANCER FORUM

September 25th-26th, 1975
Fort Smith, Arkansas

This one and one-half day meeting will be held at the Sheraton Inn in Fort Smith, September
25th-26th, 1975.

Guest speakers from Memorial Hospital, New York City and the Sloan Kettering Institute will
highlight the program.

Further details to be announced later.

226

Oklahoma State Medical Association

SANATORIUM CLOSES. GENERAL
HOSPITALS TO CARE FOR
TUBERCULOSIS PATIENTS

Oklahoma’s last tuberculosis sanatorium,
located at Talihina, became an Oklahoma
Veterans Center on July 1st, 1975. In the fu-
ture, a few tuberculosis patients requiring
hospitalization will be admitted to one of four
general hospitals. (Tuberculosis is now largely
treated on an outpatient basis. When hos-
pitalization is required, it is usually because of
some associated non-tuberculous condition.)
Designated physicians on the staffs of these
hospitals will provide the medical care. Pay-
ment for services will be made through a state
TB payment plan administered by the Division
of Tuberculosis and Respiratory Diseases of the
State Department of Health. This plan will
provide funds for hospitalization and medical
care, less any insurance or third party pay-
ments.

Physicians’ requests for patient admission
are to be made by telephone to the Director of
the Tuberculosis and Respiratory Disease Di-
vision, State Department of Health, Oklahoma
City, Oklahoma, Area Code 405, 271-4063. To
be eligible for admission, the patient should

News From
The Oklahoma State
Department of
Health

have a diagnosis of active tuberculosis. Pa-
tients with atypical mycobacteriological dis-
ease are not eligible for hospitalization under
this plan.

The accompanying map shows the location of
designated hospitals and the areas each serves
for TB patients requiring hospitalization under
the state payment plan. □

Where TB Patients Will Be Hospitalized
Under The State Tuberculosis Payment Plan

COMMUNICABLE DISEASES IN OKLAHOMA FOR MAY, 1975

DISEASE

May

1975

May

1974

April

1975

Total To Date
1975 1974

Amebiasis

Brucellosis

—

Chickenpox

213

167

159

887

695

Encephalitis, Infectious

Gonorrhea (Use Form ODH-228)

940

938

1104

5009

4323

Hepatitis, A, B, Unspecified

370

487

Leptospirosis

—

Malaria

—

Meningococcal Infections

—

Meningitis, Aseptic

Mumps

131

308

Rabies in Animals

Rheumatic Fever

Rocky Mountain Spotted Fever

Rubella

Rubella, Congenital Syndrome

—

Rubeola

Salmonellosis

107

Shigellosis

155

Syphilis, Infectious

(Use Form ODH-228)

Tetanus

—

Tuberculosis, New Active

138

119

Tularemia

—

Typhoid Fever

—

Whooping Cough

For Consultation Call: (405) 271-4060

Journal / July 1975 / Volume 68

227

news

OSMA Public Relations Program Underway

Under the leadership of the association’s
Public Policy Council, a public relations pro-
gram designed to inform Oklahomans about
the deleterious affect of the new utilization re-
view regulations, and other eminent federal
activities, is underway.

Arnold G. Nelson, MD, the association’s
President just barely had time to name the
council and its chairman, Joe Crosthwait,
MD, before it went to work. Its initial activity
centered around the utilization review reg-
ulations that were published on November
29th, 1974, by the Secretary of HEW, Caspar
Weinberger.

Initially, the OSMA had taken a position of
attempting to help hospitals implement the
utilization review regulations. In January the
Board of Trustees authorized the association’s
Foundation For Peer Review to publish a man-
ual containing admitting criteria, standards
and information regarding length of stay, to be
distributed to all hospitals in the state. In addi-
tion, the association was instrumental in the
formation of a Utilization Review Task Force
made up of all parties concerned with the im-
plementation of the new regulations: The
Oklahoma Hospital Association, Osteopathic
Association, Nursing Home Association, Okla-
homa Health Department Hospital Licensing
Section, State Welfare Department, and the
Part A and Part B Medicare Carriers.

This Task Force conducted a series of semi-
nars throughout the state to assist hospitals in
implementing the regulations, if possible. It
quickly became obvious that many hospitals
would not be able to implement the regulations
at all, and could possibly lose their Medicare
reimbursements.

In February, the AMA filed a lawsuit in the
Federal District Court of the Northern District
of Illinois attacking the constitutionality of the
regulations as published. At the same time, a
ground swell of opposition to the regulations
began to develop that ultimately cumulated in

228

a resolution being adopted by the OSMA House
of Delegates at its annual meeting on April
25th.

That resolution stated, "that the physicians
of the state of Oklahoma will continue utiliza-
tion review and peer review on an individual
hospital basis, and will not participate in utili-
zation review as outlined in the (November
29th) cited regulations . . ”

That resolution called for the association to
organize a public information campaign and
authorize the association’s Board of Trustees to
institute a voluntary assessment to establish
an adequate budget for such a campaign. Each
member of the state medical association was
asked to contribute $100. As of mid-June,
nearly $40,000 had been voluntarily contri-
buted.

Immediately after the OSMA House of Dele-
gates annual meeting the association’s Council
on Public Policy employed a public relations
firm from Tulsa to prepare the necessary pub-
lic relations campaign material. This same
firm, Schnake and Associates, Inc., had hand-
led the association’s Oklahoma University
Health Sciences Center Campaign in 1974.

Under the guidance of Joe Crosthwait, MD,
council chairman, the aim of the PR campaign
was to generate at least 100,000 letters to Pres-
ident Gerald Ford urging him to have the
Secretary of HEW withdraw the utilization re-
view regulations. Officially the campaign was
to begin on June 13th, with a press conference
in Oklahoma City and Tulsa. The campaign
was to center around a series of newspaper ads
to appear in every state daily newspaper dur-
ing the week of June 15th. The headline, in one
and one-half inch type, was to read "WARN-
ING! A NEW FEDERAL REGULATION MAY
BE DANGEROUS TO YOUR HEALTH.” This
was to be followed by large-type copy, easily
read, explaining that HEW was attempting to
ration medical care to Medicare and Medicaid

Oklahoma State Medical Association

recipients by instituting a plan of cost control
under the guise of "quality” control.

The campaign did not start on June 13th.
Instead, Judge Julius Hoffman of the Federal
District Court in Illinois issued a preliminary
injunction instructing the Secretary of HEW
not to enforce the new regulations. OSMA
leadership decided to take a "wait and see” at-
titude before launching its PR campaign. In
the meantime, however, it continued to gear up
in case it became necessary to go to the public.

While the judge’s ruling was only "round
one” in what could be a lengthy legal battle by
the American Medical Association to defeat
the utilization review regulations, it was a vic-
tory. Until there is a final ruling in the case, or
until a higher court overturns Judge
Hoffman’s preliminary injunction, hospitals
throughout the nation will operate under the
old utilization review regulations.

While the Public Policy Council was gearing
up for a public relations campaign, it was not
ignoring another approach to the utilization
review problem, ie the creation of a peer review
plan that would meet the requirements of the
law and that would be acceptable to Oklahoma
physicians.

Through its Executive Committee the Coun-
cil worked up a number of model peer review
plans that might meet the qualifications for
utilization review under the federal law, not
necessarily those specified in the regulations.

The idea for a uniform plan, one that would
be adaptable by any hospital in the state, came
out of a trip to Washington, DC, by repre-
sentatives from the council. Senator Henry
Bellmon, acting as liaison, established a meet-
ing between some top HEW officials and Doc-
tors Joe Crosthwait, Kent Braden, Ken Whit-
tington, and Arnold Nelson.

The idea for a uniform plan was brought
back to Oklahoma for possible implementa-
tion. The OSMA staff was instructed to at-
tempt to draw up such a plan in consultation
with the various organizations that would be
affected by it. The uniform plan that came out
of this effort was a result of many consultations
followed by rewrites.

It was originally thought that when the plan
was finally perfected it would be taken back to
Washington and presented to the Secretary of
HEW. If the Secretary accepted the plan, it
would then be published and distributed to all
hospitals and physicians in the state for im-
plementation in their local areas. If the Secre-
tary rejected the plan, this rejection would be-

come a portion of the public relations campaign
to show that he had placed himself in an inflex-
ible position and was unwilling to compromise.

Since the ruling by the federal judge, all ac-
tivities in regard to utilization review are
being held in abeyance. The public relations
campaign is ready, and the uniform plan is in
its final stages of completion. If necessary,
either or both of these activities can be re-
started at a moment’s notice.

In the meantime, the Public Policy Council
has taken on another activity. A portion of
Public Law 92-603, the Social Security
Amendments of 1972, specifies that there is to
be a ceiling on physicians’ fees paid under Med-
icare based on physicians’ charges for calen-
dar year 1971 plus an increase related to an
"economic index.”

The implementing regulations on this sec-
tion of the law will result in a rollback of
physicians’ allowable fees to the 1969 level. Al-
though the law states "1971,” the charged data
in the Medicare computers for that year was
based on physicians’ charges in 1969.

The net result of this rollback will be that
patient-beneficiary will see their Medicare
reimbursement checks cut and there will be a
greater discrepancy between the amount
physicians are currently charging and the
amount Medicare is recognizing as "allow-
able.”

The Secretary of HEW has announced that
he will allow a maximum of 17.93 percent in-
crease over fees being charged in 1971. It is
estimated that fully 80 percent of all current
charges being recognized by Medicare and
Medicaid would be reduced.

L. E. Rader, Director of the Oklahoma Wel-
fare Department, objected to the new reg-
ulations and stated, "as proposed (they) would
result in significant, widespread reductions of
allowable charges below the current allowable
charges. On unassigned claims, this will result
in reduced payments to beneficiaries and could
result in a sharp decrease in assignments.
Many beneficiaries will be asking why Medi-
care is paying lower allowable charges than
previously.”

The association’s Public Policy Council is in
the process of drawing up a folder or brochure
to be placed in every physicians’ office in the
state explaining the reimbursement rollbacks
to Medicare patients. These brochures would
be made available at cost to physicians for dis-
tribution to all of their Medicare and Medicaid
patients. □

Journal / July 1975 / Volume 68

229

BEVERLY HILLS HOSPITAL
BEVERLY HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

PSYCHIATRY

Jackson H. Speegle, MD
John T. Holbrook, MD

Fred H. Jordan, MD
Joseph H. Lindsay, MD

PSYCHOLOGY

George R. Mount, PhD Tom I. Payton, MS

Donald L. Whaley, PhD Patrick R. Barnes, MS

EDUCATION DIRECTOR

William E. Nix, PhD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND R.T. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

230

Oklahoma State Medical Association

Weinberger Responds to
Nelson Letter

HEW Secretary Caspar Weinberger has per-
sonally responded to a letter from OSMA
President, Arnold Nelson, MD, requesting that
the utilization review regulations published on
November 29th, 1974, be withdrawn.

In his response the Secretary commented on
each of four primary reasons given by Doctor
Nelson for the withdrawal. In the following
transcript of that letter, the sections set off by
alphabetized designations are the reasons
stated by Doctor Nelson.

Following each such designated statement is
Secretary Weinberger’s response.

"(a) As many as 50 rural Oklahoma hospitals
that neither have the medical staff nor the per-
sonnel to comply with the regulations would
close.

"This problem is being addressed and re-
solved through technical assistance provided
by our Dallas Regional Office to representa-
tives of rural hospitals in Oklahoma. Utiliza-
tion review committees are being formed in
compliance with the third alternative of Sec-
tion 405.1035(e) of the Medicare regulations
. . . 'by a group established and organized in a
manner approved by the Secretary that is cap-
able of performing such function (utilization
review).’ This alternative was provided in the
regulations to accommodate facilities that do
not have an in-house capability to perform re-
view functions. The alternative allows utiliza-
tion review committees to be composed of elig-
ible personnel from outside the facility. Such
committees may perform utilization reviews
for several hospitals.

"(b) The regulations violate the right of
physicians to determine the medical treatment
considered best for their patients.

"The regulations require the use of norms,
criteria, and standards that physicians either
developed or selected for use by the utilization
review committee in reviewing the necessity
for admissions and continued stays and con-
ducting medical care evaluation studies. These
norms, criteria, and standards, however, are to
be used only as screening mechanisms. When
admissions or continued stays do not fall with-
in the screening, the attending physician is af-
forded an opportunity to provide justification
for such. The attending physician’s views and
decisions may only be disallowed by at least
two concurring physician members of the
Utilization Review Committee. This procedure

Journal / July 1975 / Volume 68

should enhance the attending physician’s
determination of medical treatment rather
than violate his right to make such determina-
tions.

"(c) For Medicare and Medicaid patients, the
regulations will result in many medical deci-
sions being made by people not licensed to
practice medicine.

"Only physician members of the Utilization
Review Committee are allowed to make medi-
cal decisions. A trained review coordinator,
using physician-developed or selected norms,
criteria, and standards, will screen cases
against the physician-developed data. Cases
not passing the screen will be automatically
referred to a physician committee member for
further evaluation and preliminary medical
determination. As stated above, no final ad-
verse medical decisions will be made before
consulting the attending physician.

"(d) Implementation of the regulations will
place constraints not legislated by Congress
upon benefits promised to Medicare and Medi-
caid recipients.

"Congressional legislation was predicated on
the conviction that beneficiaries of federal pro-
grams deserve the best possible health care
and that every federal health care dollar
should be wisely spent. The regulations were
developed with that mandate in mind and will
afford hospitals and other providers an effic-
ient model for quality assurance.”

In closing his letter, Secretary Weinberger
stated, "we continue to support the concept of
the utilization review regulations. As you may
know, the US District Court of Northern Illi-
nois has issued a preliminary injunction
against the implementation of the Utilization
Review Regulations. The department is cur-
rently studying that injunction order to deter-
mine what further steps are necessary.” □

Remember These Dates -

MAY 5th, 6th, 7th, 8th, 1976

Oklahoma Medical Summit ’76

A combined meeting of the Oklahoma
State Medical Association, the Oklahoma
City Clinical Society and the Oklahoma
Academy of Family Physicians.

231

news

Putnam City High School Teacher
Receives OSMA Award

Mrs. Pat Lukehart, center above, is shown
as S. N. Stone, MD, Speaker of the OSMA House
of Delegates presents her with a check for a
$250 expense-paid trip to Washington, D.C.
Also attending the presentation was John Har-
ris, Advice Chairman of the Governor’s Com-
mittee on Employment of the Handicapped.

The award presentation was held March
26th, 1975, at 1:00 p.m., in the Second floor
Conference Room of the State Capitol in Okla-
homa City.

Each year the OSMA sponsors the trip for
the teacher of the essay winner of the '"Ability
Counts” contest which is sponsored by the Gov-
ernor’s Committee on Employment of the
Handicapped. This year’s winner was Cin-
dy Miller, Putnam City High School stu-
dent, and her winning paper is printed on page
225 of this issue of The Journal. □

Life Certificates Awarded
Three Tulsa Physicians

During a quarterly meeting of the Tulsa
County Medical Society, three Tulsa physi-
cians were awarded Life Membership Certifi-
cates by the Oklahoma State Medical Associa-
tion. The ceremonies were held May 12th, 1975,.
at the Children’s Medical Center in Tulsa.

Pictured (left to right) are Jack L. Richard-
son, MD, immediate Past-President of the
OSMA, shown making the presentations; Felix
O. Durham, MD, Francis W. Pruitt, MD, and
James G. Moore, MD.

Doctor Durham has practiced psychiatry in
Tulsa since 1973 and previously was in prac-
tice in New York City.

Doctor Pruitt came to Tulsa in 1959 follow-
ing his retirement as a Brigadier-General in
the US Army during which time he served as a
personal physician to General Dwight D.
Eisenhower. His specialty is internal medicine.

Also retiring as a Brigadier-General in the
US Army in 1962, Doctor Moore practiced in
Tulsa until his retirement two years ago. He
practiced general preventive medicine and oc-
cupational medicine. □

NEW MEDICAL OFFICES FOR LEASE

34’ x 52’, Ground Level, Plan to Suit
5320 North Portland

(Across From Deaconess Hospital)

Contact Bryce Petrie, MD 942-0600

232

Oklahoma State Medical Association

Proceedings of the 69th Annual Session of the House of Delegates

of the

Oklahoma State Medical Association

OPENING SESSION

I. CALL TO ORDER:

The House of Delegates convened its 69th
Annual Session in the Lincoln Plaza Inn,
Oklahoma City, Oklahoma, on April 23, 1975.
The Speaker, S. N. Stone, MD, Oklahoma City,
called the meeting to order at 2:50 p.m.

II. INVOCATION:

John A. Blaschke, MD, Oklahoma City, de-
livered the invocation.

III. REPORT OF THE CREDENTIALS
COMMITTEE:

The presence of a quorum was reported by
Jack D. Fetzer, MD, Chairman, Woodward.

IV. APPOINTMENT OF COMMITTEES OF
THE HOUSE:

Doctor Stone announced the appointment of
the following committees to assist in the con-
duct of the meeting:

CREDENTIALS COMMITTEE

Jack D. Fetzer, MD, Woodward, Chairman
William G. Bernhardt, MD, Midwest City
Edward W. Allensworth, MD, Vinita
Carl H. Guild, MD, Bartlesville
Joe B. Jarman, MD, Enid
Jack D. Honaker, MD, Frederick
Lynwood Heaver, MD, Tulsa
T. C. Alexander, MD, Okmulgee

TELLERS

Ray V. McIntyre, MD, Kingfisher, Chairman

Kent Braden, MD, Oklahoma City

Henry Wolfe, MD, Hugo

Clarence P. Taylor, MD, Ada

Billy Dale Dotter, MD, Okeene

William Z. Cook, Jr., MD, Stilwell

William M. Benzing, Jr., MD, Tulsa

Yale E. Parkhurst, MD, Miami

M. R. Jennings, MD, Claremore

SERGEANTS AT ARMS
Scott Hendren, MD, Oklahoma City, Chair-
man

Harlan Thomas, MD, Tulsa
Casey Truett, MD, Norman

REFERENCE COMMITTEE NO. I
Arthur F. Elliott, MD, Oklahoma City, Chair-
man

J. William McDoniel, MD, Chickasha

Elvin M. Amen, MD, Bartlesville

David Browning, Jr., MD, Tulsa

R. L. Winters, MD, Poteau

Charles Tefertiller, MD, Altus

Rollie Rhodes, Jr., MD, Tulsa

Robert A. McLauchlin, MD, Oklahoma City

Jack L. Berry, MD, Okarche

Don Blair, Staff

REFERENCE COMMITTEE NO. II
Robert M. Shepard, Jr., MD, Tulsa, Chairman
John A. Blaschke, MD, Oklahoma City
E. C. Yeary, MD, Ponca City
Frank Adelman, MD, Enid
Irwin H. Brown, MD, Oklahoma City
James S. Jones, MD, Duncan
George M. Brown, Jr., MD, McAlester
Samuel C. Jack, MD, Lawton
David Bickham, Staff

REFERENCE COMMITTEE NO. Ill
Jack W. Parrish, MD, Seminole, Chairman
Chester L. Bynum, MD, Norman
J. Harold Tisdal, MD, Clinton
E. L. Leonard, MD, Wagoner
A. C. Roberson, MD, Anadarko
David D. Rose, MD, Ardmore
Charles W. Cathey, MD, Oklahoma City
Fred R. Martin, MD, Tulsa
Ed Kelsay, Staff

V. INTRODUCTION OF SPECIAL GUESTS:
Mrs. John W. Williams, Retiring President
of the Woman’s Auxiliary to the Oklahoma
State Medical Association was introduced and
brought greetings to the OSMA House of Dele-
gates.

Mrs. William B. Renfrow, Incoming Presi-
dent of the Woman’s Auxiliary to the Okla-
homa State Medical Association, and Doctor
Malcolm Todd, President of the American
Medical Association, were introduced. Doctor

(Continued on Page 243)

Journal / July 1975 / Volume 68

233

HEALTH CARE MANAGEMENT

MASSES OF PAPERWORK AND SLOW RECEIVABLES
these two enemies are overwhelming todays Medical
Office! How to deal with these two is the “number one
business problem” for many doctors.

HCM's system is simple, easy to learn, requires no
special equipment, is flexible, and can follow along the
lines of your present business office procedures.

For further information, contact:
Gene Highfill

Academy Computing Corporation
3535 NW 58th — Suite 102
Oklahoma City, Oklahoma 73112
405/947-7746

SPONSORED BYTHE OSMA

Washington National Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE
DISABILITY INCOME INSURANCE

Contact Association Counselors:

Jim Thaxtoo, Bill Howard or Rodman A. Frates

Administrators

720 NW 50th
PC Box 18593

405 842-3735

Oklahoma City 73118

234

Oklahoma State Medical Association

NELSON NAMES COUNCILS AND COMMITTEES

Arnold G. Nelson, MD, President of the
Oklahoma State Medical Association, has re-
leased a tentative list of his appointments.
Standing committees and councils are

established in the OSMA Bylaws, while special
committees are designated by the President to
carry out specific functions under the jurisdic-
tion of appropriate councils.

OSMA STANDING COMMITTEES

CONSTITUTION AND BYLAWS
COMMITTEE

Lewis C. Taylor, MD, Chairman (1978)
Jerold D. Kethley, MD (1977)

George H. Garrison, MD (1976)

Floyd F. Miller, MD (1977)

Richard Wade, MD (1976)

Bob J. Rutledge, MD (1978)

GRIEVANCE COMMITTEE

Hillard E. Denyer, MD, Chairman
Lucien M. Pascucci, MD, Vice-Chairman
Ed L. Calhoon, MD
Stanley R. McCampbell, MD
Jack L. Richardson, MD

MEDICAL CENTER LIAISON
COMMITTEE

C. S. Lewis, Jr., MD, Chairman (1975)
Robert S. Ellis, MD (1976)

Jack Parrish, MD (1976)

Thomas N. Lynn, MD (1976)

Orange M. Welborn, MD (1977)

Earl M. Bricker, MD (1977)

David C. Mock, MD
Wendell L. Smith, MD (1977)

Robert J. Rutledge, MD (1977)

Howard P. Mauldin, MD (1976)

Billy Dale Dotter, MD (1977)

James W. Murphree, MD (1976)

G. Rainey Williams, MD (1976)

M. Boyd Shook, MD (1977)

C. B. Cunningham, MD (1976)

William Thurman, MD
Malcom E. Phelps, MD (1977)

COMMITTEE ON PLANNING

Jack L. Richardson, MD, Chairman

M. Joe Crosthwait, MD
Kenneth W. Whittington, MD
John A. McIntyre, MD
Schales L. Atkinson, MD
Roger J. Reid, MD
S. N. Stone, MD
Marion C. Wagnon, MD
Arnold G. Nelson, MD
C. Alton Brown, MD
Orange M. Welborn, MD

FINANCIAL AID TO EDUCATION
COMMITTEE

Lucien M. Pascucci, MD, Chairman
Stanley R. McCampbell, MD
Jack L. Richardson, MD
Arnold G. Nelson, MD
Orange M. Welborn, MD

MEDICAL-DENTAL LIAISON
COMMITTEE

Orange M. Welborn, MD, Chairman

Kent Braden, MD

Kenneth W. Whittington, MD

Don Blair, Ex-Officio

C. S. Lewis, Jr., MD

M. Joe Crosthwait, MD

Orange M. Welborn, MD

PHYSICIAN S COMMITTEE

Ed L. Calhoon, MD, Chairman
M. Joe Crosthwait, MD
Martin H. Andrews, MD
Arthur F. Elliott, MD
James B. Eskridge, III, MD
Robert A. McLaughlin, MD

OSMA COUNCILS AND COMMITTEES

COUNCIL ON INSURANCE

C. Alton Brown, MD, Chairman
C. E. Woodard, MD
William M. Leebron, MD
Robert A. Nelson, MD
Howard A. Bennett, MD
Robert W. Kahn, MD
William G. Bernhardt, MD
Glen L. Berkenbile, MD
Thomas C. Glasscock, MD
Jack L. Berry, MD

COUNCIL ON CONTINUING MEDICAL
EDUCATION

Kenneth W. Whittington, MD, Chairman

Royce B. Means, MD

Ralph L. Buller, MD

Clarence P. Taylor, MD

John W. Drake, MD

Jack W. Parrish, MD

W. Ed Dalton, MD

John R. Adair, MD

Irwin H. Brown, MD

Journal / July 1975 / Volume 68

235

news

David E. Browning, Jr., MD
James F. Tagge, MD
James D. Loudon, MD
James C. Smith, MD
John A. Blaschke, MD
Wendell L. Smith, MD
Hal B. Vorse, MD

COUNCIL ON PROFESSIONAL &
INTERVOCATIONAL RELATIONS

Marion C. Wagnon, MD, Chairman

Frank W. Clark, MD

Floyd F. Miller, MD

Fred W. Sellers, MD

Donald F. Rhinehart, MD

Norman A. Cotner, MD

Bryce O. Bliss, MD

Marvin K. Margo, MD

David P. Mitchell, MD

MEDICAL-LEGAL RELATIONS
COMMITTEE

Marvin K. Margo, MD, Chairman
A. Munson Fuller, MD
Tim K. Smalley, MD
Robert T. Rounsaville, MD
William H. Oehlert, MD
Richard G. Dotter, MD
John T. Keown, Jr., MD
Joseph F. Messenbaugh, III, MD
George R. Randels, MD
Charles E. Beck, MD

CLAIMSMEN LIAISON COMMITTEE

Richard H. Burgtorf, MD, Chairman

Orange M. Welborn, MD

David R. Brown, MD

Donald F. Rhinehart, MD

James P. Bell, MD

Daniel R. Storts, MD

COUNCIL ON PUBLIC HEALTH

Schales L. Atkinson, MD, Chairman

Glen L. Berkenbile, MD

C. Thomas Thompson, MD

Hayden H. Donahue, MD

R. LeRoy Carpenter, MD

Nolen L. Armstrong, MD

Samuel A. Wheeler, MD

Charles E. Synith, Jr., MD

Norman L. Haug, MD

Donald L. Cooper, MD

Daniel F. Keller, MD

Armond H. Start, MD

Jim H. Earls, MD

SPORTS MEDICINE COMMITTEE

Don O’Donoghue, MD, Chairman
Donald L. Cooper, MD
Donald F. Robinson, MD
Leonard Diehl, MD
James P. Bell, MD
Joe B. Jarman, Jr., MD
Samuel A. Wheeler, MD

COMMITTEE ON ALCOHOLISM AND
DRUG ABUSE

Jim H. Earls, MD, Chairman
E. Edwin Fair, MD
Thomas M. Donica, MD
Alfonso Paredes, MD
Pamela R. Parrish, MD
V. M. Rutherford, MD
J. Hartwell Dunn, MD
Donald F. Cooper, MD
Ray V. McIntyre, MD
J. R. Drumwright, MD
Nolen L. Armstrong, MD

COMMITTEE ON IMMUNIZATION

Armond H. Start, MD, Chairman
William L. Edwards, MD
R. LeRoy Carpenter, MD
Burdge F. Green, MD
Ralph E. Murphy, MD
James E. Mays, Jr., MD
John C. Kramer, MD
Harris D. Riley, Jr., MD
Y. E. Parkhurst, MD
Delmar L. Gheen, Jr., MD
George W. Prothro, MD
Quillen M. Hughes, MD

COMMITTEE ON LABORATORY
QUALITY

Daniel F. Keller, MD, Chairman

Byron F. Smith, MD

Bryce O. Bliss, MD

Robert L. Alexander, Jr., MD

Bill E. Blevins, MD

John F. DeJarnette, MD

M. Boyd Shook, MD

Dale E. VanWormer, MD

J. William Hood, MD

MATERNAL MORTALITY COMMITTEE

Schales L. Atkinson, MD, Chairman

James A. Merrill, MD

Max Deardorff, MD

Sara DePersio, MD

Paul A. Bischoff, MD

Jed E. Goldberg, MD

James R. McFarland, MD

Matthew B. Moore, MD

J. W. McDoniel, MD

Frank D. Barnett, MD

COUNCIL ON PUBLIC POLICY

M. Joe Crosthwait, MD, Chairman

R. Barton Carl, MD, Vice-Chairman

Charles N. Atkins, MD

Gerald L. Beasley, Jr., MD

Kent Braden, MD

Eugene S. Bell, MD

James B. Eskridge, III, MD

Jack Fetzer, MD

James Funnell, MD

Tom S. Gafford, MD

Edward D. Greenberger, MD

Homer D. Hardy, MD

Floyd F. Miller, MD

Jake Jones, MD

Rex Kenyon, MD

236

Oklahoma State Medical Association

Jerold D. Kethley, MD
William M. Leebron, MD
Jack L. Richardson, MD
Casey Truett, MD
Marion C. Wagnon, MD
Orange M. Welborn, MD
Kenneth W. Whittington, MD
George Randels, MD
Harlan Thomas, MD

FOREIGN TRAVEL COMMITTEE

J. R. Stacy, MD, Chairman
Elvin M. Amen, MD
Allen E. Greer, MD
Paul D. Patzkowsky, MD
Milton J. Sugarman, MD
John T. Keown, Jr., MD

MEDICAL HERITAGE COMMITTEE

R. Palmer Howard, MD, Chairman
Clinton Gallaher, MD

B. E. Blevins, MD
Vance Bradford, MD
Neil B. Kimerer, MD
E. C. Mohler, MD
Harold J. Black, MD
George H. Garrison, MD

EXECUTIVE COMMITTEE

Arnold G. Nelson, MD
Jack L. Richardson, MD
Orange M. Welborn, MD
William M. Leebron, MD
Haven W. Mankin, MD

S. N. Stone, MD
Jack D. Fetzer, MD
John A. McIntyre, MD

STATE LEGISLATIVE COMMITTEE

R. Barton Carl, MD, Chairman

S. N. Stone, MD
Royce C. McDougal, MD
Joseph W. Stafford, MD
James B. Lockhart, MD
William G. Bernhardt, MD
Edgar W. Young, Jr., MD
George H. Kamp, MD
Lanny F. Trotter, MD
Karl K. Boatman, MD
Robert S. Ellis, MD

John R. Smith, MD
Marion C. Wagnon, MD
Perry A. Lambird, MD
M. K. Braly, MD
Worth M. Gross, MD
William L. Hughes, MD
Wilbur C. Lewis, MD

COUNCIL ON SOCIOECONOMIC
ACTIVITIES

Roger J. Reid, MD, Chairman
Walter E. Brown, MD
Howard B. Keith, MD
Robert R. Dugan, MD
Leon N. Gilbert, MD
Ann K. Kent, MD
Roger V. Haglund, MD
Ed L. Calhoon, MD

Robert Sukman, MD
Kenneth L. Evans, MD

PEER REVIEW COMMITTEE (A)

Tony Puckett, MD, Chairman
Jack L. Richardson, MD
Robert M. Shepard, Jr., MD
Frank L. Adelman, MD
Samuel A. Wheeler, MD
Bobby Gene Smith, MD
John A. McIntyre, MD
Roger V. Haglund, MD
Leonard H. Brown, MD
William R. McShane, MD
Robert G. Small, MD
Clarence Robison, Jr., MD
Lowell N. Templer, MD
Gerald W. McCullough, MD

PEER REVIEW COMMITTEE (B)

Tony Puckett, MD, Chairman
Arthur E. Schmidt, MD
Joseph Salamy, MD
William E. Hood, Jr., MD
Neil B. Kimerer, MD
David D. Rose, MD
Leon D. Combs, MD
Alfred H. Bungardt, MD
Thomas H. Henley, MD
Bill G. Henley, MD
S. Fulton Tompkins, MD
Richard M. Taliaferro, MD
William J. Forrest, MD
David B. Brinker, MD
Schales L. Atkinson, MD
Michael Berkey, MD
Victor L. Robards, Jr., MD
Fred D. Switzer, MD

PEER REVIEW CONSULTANTS

Robert Morgan, MD
Kent Braden, MD
Robert L. Imler, Jr., MD
William B. Renfrow, MD
Thomas L. Ashcraft, MD
Lyle W. Burroughs, MD
Charles J. Wine, MD
A. Munson Fuller, MD
Gerald W. Boles, MD
James E. Mays, Jr., MD

OCCUPATIONAL MEDICINE
COMMITTEE

Robert R. Dugan, MD
R. L. Lembke, MD
James D. Green, MD
Bob J. Rutledge, MD
Casper H. Smith, MD
Mark A. Everett, MD
James G. Moore, MD
J. R. Drumwright, MD
Kieffer, D. Davis, MD
Robert G. Perryman, MD
Samuel C. Jack, MD
W. Frank Phelps, MD
William A. Miller, MD
James B. Wise, MD

Journal / July 1975 / Volume 68

237

news

EMERGENCY MEDICAL SERVICES
COMMITTEE

Arthur F. Elliott, MD, Chairman
Harry B. Tate, MD
Gerald E. Gustafson, MD
Gerald W. McCullough, MD
Barney J. Limes, MD
Kenneth L. Evans, MD

Arkansas-Oklahoma Cancer Forum
Will Convene in September

The Annual Arkansas-Oklahoma Cancer
Forum will be held at the Sheraton Inn in Fort
Smith, Arkansas, September 25th-26th, 1975.
The day and a half program has been de-
veloped in cooperation with the Memorial Hos-
pital and Sloan Kettering Institute of New
York City.

A complete program follows:

CURRENT CONCEPTS IN CARE
OF THE CANCER PATIENT

Morning Session: Thursday, September 25th,
1975

Chairman: Frank H. McGregor, MD, Presi-
dent, Oklahoma Division, Inc., American
Cancer Society, Oklahoma City

8:25 — 8:30 Welcome and Opening Remarks
— Frank H. McGregor, MD

8:30—9:10 THE CLINICAL ROLE OF THE
PATHOLOGIST IN THE MANAGE-
MENT OF PATIENTS WITH CANCER
Paul Rosen, MD, Associate Attending
Pathologist, Department of Pathology,
Memorial Sloan-Kettering Cancer
Center, New York City
9:10—9:50 MANAGEMENT OF BENIGN
LESIONS OF THE LOWER GI TRACT
Stuart Quan, MD, Associate Attending
Surgeon, Rectal and Colon Service, De-
partment of Surgery, Memorial Sloan-
Kettering Cancer Center, New York City
9:50 — 10:05 Intermission

10:05—10:45 PRACTICAL MANAGEMENT
OF PATIENTS WITH OVARIAN CAR-
CINOMA

James H. Freel, MD, Assistant Attending
Surgeon, Gynecology Service, Depart-
ment of Surgery, Memorial Sloan-
Kettering Cancer Center, New York City

10:45—11:25 WHAT’S BEST FOR THE PA-
TIENT

Charles Kelley, MD, Assistant Attending
Radiation Therapist, Department of
Radiation Therapy, Memorial Sloan-
Kettering Cancer Center, New York City

11:25—12:05 PSYCHIATRIC SUPPORT OF
THE CANCER PATIENT
Fred O. Henker, MD, Associate Professor
of Psychiatry, University of Arkansas
Medical Center, Little Rock

Afternoon Session: Thursday, September 25th,
1975

Chairman: Fred Caldwell, MD, President, Ar-
kansas Division, Inc., American Cancer
Society, Little Rock, Arkansas

1:30—2:10 RESULTS OF BREAST
SCREENING IN OKLAHOMA
JoAnn Haberman, MD, PhD, Director of
Oklahoma Breast Screening Project and
Associate Professor, Department of
Radiology, University Health Sciences
Center, Oklahoma City

2:10—2:50 SPECIMEN RADIOGRAPHY IN
BREAST CANCER
Paul Rosen, MD

2:50—3:30 RATIONALE FOR MANAGE-
MENT OF PATIENTS WITH POTEN-
TIALLY CURABLE BREAST CANCER
Guy F. Robbins, MD, Attending Surgeon,
Breast Service Department of Surgery,
Memorial Sloan-Kettering Cancer
Center, New York City

3:30 — 3:45 Intermission

3:45 — 4:25 PRACTICAL MANAGEMENT
OF PATIENTS WITH ENDOMETRIAL
CARCINOMA
James H. Freel, MD

4:25—5:05 IMMUNI-THERAPY IN PEDI-
ATRIC PATIENTS WITH MALIGNAN-
CIES

G. Bennett Humphrey, MD, Chief
Hemotology-Oncology Service, Oklahoma
Children’s Memorial Hospital, Associate
Professor, Department of Pediatrics, Uni-
versity of Oklahoma Health Sciences
Center

Morning Session: Friday, September 26th,
1975

Chairman: Robert Janes, MD, President,
Sebastian County Unit, American Cancer
Society, Arkansas

238

Oklahoma State Medical Association

9:00—9:40 MANAGEMENT OF MALIG-
NANT LESIONS OF THE LOWER GI
TRACT

Stuart Quan, MD

9:40—10:20 WHAT’S NEW IN RADIATION
THERAPY
Charles Kelley, MD
10:20 — 10:35 Intermission
10:35—11:15 WHAT’S NEW IN CANCER
CHEMOTHERAPY

Richard H. Bottomley, MD, Head Oncol-
ogy Division, Department of Medicine,
University Hospital, University of Okla-
homa Health Sciences Center
11:15—11:55 READAPTATION OF CAN-
CER PATIENTS TO SOCIETY
Guy F. Robbins, MD
11:55 Adjournment

There is no registration fee for the meeting.
All members of the medical profession, reg-
istered nurses and medical students are urged
to attend this informative session. Category 1
credit will be offered by the American Medical
Association and the prescribed credit offered
by the American Academy of Family
Practice. □

DEATH

JOEL S. PRICE, MD
1902-1975

A longtime Oklahoma City surgeon,
Joel S. Price, MD, died June 14th, 1975.
Born in Dewey County, Oklahoma,
Doctor Price was graduated from the
University of Oklahoma College of
Medicine in 1928. He practiced in
Oklahoma City for forty years before
his retirement in 1967. Doctor Price
was a member of the Oklahoma Acad-
emy of Family Practice and a member of
the Phi Chi medical fraternity. □

Oklahoma Physicians Tagged
For Neurosurgical Society Offices

Two Oklahoma physicians have been named
to office in the Rocky Mountain Neurosurgical
Society for 1975-76. They are Robert L. Imler,
MD, Tulsa as President and Alvin Rix, MD,
Oklahoma City as Vice-President. □

Offering complete private Psy-
chiatric Services using the
Therapeutic Community ap-
proach in an open setting.

Fully Accrediated
60 Beds

MEDiCENTER PSYCHIATRIC
HOSPITAL

1505 Eighth Wichita Falls, Texas 76301

Services Available

• Psychotherapy Individual and Group

• Chemotherapy

• Recreational Therapy

• Occupational Therapy

• Psychological Testing

• Psychiatric Social Worker Services

• Neurological Consultation

• Electro-Convulsive Therapy

• Clinical Laboratory

• X-ray

• Pharmacy

• Physical Therapy

• Medical Consultations

Journal / July 1975 / Volume 68

239

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance
Springfield, Mass.

For additional details and application form, please contact

Jim Thaxton

Administrator

Telephone 405 848-7661
Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

DOCTOR, WHAT WILL YOU EARN?

It depends, of course, on your age and annual earnings, but the amount can quite reasonably
exceed $400,000.

Is this logical? Not when you can participate in the . . .

O.S.M.A. GROUP DISABILITY INCOME PROGRAM

Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION
. . . gives you individual coverage at low group rates.

. . . offers flexible waiting periods at your option.

. . . guarantees you an income when you are disabled from an accident or sickness.

. . . offers optional Indemnity from $200. 00 to $2, 500. 00 per month.

. . . pays for lifetime on accident and up to age 65 on sickness.

For Additional! information, call or write

Jim Thaxton, Bill Howard or Rodman A. Prates
C. L PRATES & COMPANY, INC

720 N.W. 50th P.O. Box 18695
OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848-7661

720 N.W. 50th
P.O. Box18593

240

Oklahoma State Medical Association

Miscellaneous Advertisements

PHYSICIAN ASSOCIATES NEEDED in
family practice, cardiology, general surgery,
orthopedics, ophthalmology, ENT and OB-
GYN. Full associate status in as little as two
months. No buy-in required. This is perhaps
the number one practice opportunity in Ok-
lahoma. Inquiries confidential. Write or call
collect Chickasha Clinic, Inc., 224-4853, W. S.
Harrison, MD, or Jim Loy.

FOR SALE: NEW TEN ROOM CLINIC; two
doctors. Fully equipped, 200 M.A. x-ray, lab,
E.C.G. Large waiting room, concrete parking
lot. Hospital privileges. Henryetta. Reason for
sale, returning for residency training. Contact
Key H, The Journal, Oklahoma State Medical
Association, 601 N.W. Expressway, Oklahoma
City, Oklahoma 73118.

INTERNIST NEEDED for eight-doctor
multi-specialty group in Ardmore. This is an
excellent opportunity in a city of 23,000 people,
ideally located 100 miles south of Oklahoma
City and 100 miles north of Dallas. Excellent
clinic and hospital facilities. Ardmore has an
ideal combination of industry, farming and
ranching, and oil. Ideal recreation facilities are
available at Lake Murray, ten miles from
Ardmore. Available July 1st, 1975. C. L.
Lorentzen, MD, Medical Arts Clinic, 921 14th,
NW, Ardmore, Oklahoma 73401.

CLAREMORE, 20 MILES NORTHEAST OF
TULSA in the heart of Green Country, is in
need of family physicians and internists. Office
space is available within one block of a newly
expanded 105-bed, fully accredited hospital.
This progressive medical community is highly
desirous of attracting new physicians as soon
as possible. Interested parties should contact
Larry I. Young, MD, Drawer B, Claremore,
Oklahoma 74017, 918 341-5311.

ABILENE, KANSAS — Growing city of
8,000. Trade area, 23,000. Opportunity for
three primary care physicians. Private practice
or join an established clinic. Seventy-bed mod-
ern hospital. Skilled consultive services close
by. Excellent family living. Contact: Physician
Development Task Force 913 263-1770.

GP SURGEON, Diplomate American Board
of Family Physicians, wants practice in town
under 15,000. Wants group or share expense or
solo with trade calls and time off. Contact Key
F, The Journal, Oklahoma State Medical As-
sociation, 601 N.W. Expressway, Oklahoma
City 73118. □

NOW AVAILABLE

PROFESSIONAL LIABILITY
MEDICAL — LEGAL GUIDE FOR PHYSICIANS

PUBLISHED BY

OKLAHOMA STATE MEDICAL ASSOCIATION

Requests for the book should be directed to
the Oklahoma State Medical Association,
601 Northwest Expressway, Oklahoma City,
Oklahoma 73118.

There is no charge for this booklet.

Journal / July 1975 / Volume 68

241

ama brings continuing

medical education
(C.N.E.) to you

• Near-your hometown Recognition Award, and credit for other

• Clinical topics from practicing medicine continuing education programs

• 12 hours of Category I Continuing Medical • Presented on weekends — will not interfere
Education credit toward the AMA's Physician's with office hours

Each Regional meeting, sponsored by AMA's Council on Scientific Assembly, will consist of

eight postgraduate courses:*

1. Human Sexuality 6. Infectious Diseases and Antibiotics

2. Venereal Disease 7. Dermatology for Non-Dermatologists

3. Basic Electrocardiography 8. Basic and Advanced Life Support —

4, Pulmonary Function and Blood Gases Cardiopulmonary'Resuscitation (CPR)

5, Fluid and Electrolyte Balance

'Courses 1 through 7 are 6 hours each: each is presented twice

(once on Saturday, once on Sunday). Course No. 8 is a 12-hour course that runs both days.

Sites

Minneapolis, Minn. - July 26-27, 1975
Williamsburg, Va. - September 27-28, 1975

For more information WRITE:

Dept, of Circulation & Records/AMA, 535 N. Dearborn St./ Chicago, IL 60610
CALL (312) 751-6187 for immediate details by return mail

(Continued from Page 233)

Stone stated that Doctor Todd would be speak-
ing to the delegates later on in the program.

VI. PRESENTATIONS:

A. Doctor Don H. O’Donoghue, presented the
A. H. Robins Physician Award for Community
Service to Doctor Harry Wilkins, Oklahoma
City. .

B. Doctor Arnold G. Nelson, OSMA
President-Elect presented an AMA-ERF check
in the amount of $17,648.38 to Doctor Tom
Lynn, Dean of the OU College of Medicine.

Doctor Lynn expressed gratitude on behalf of
the OU Health Sciences Center.

VII. REMARKS OF THE SPEAKER:

Doctor Stone introduced Betty Lyles and

Suzanne Wilson as the transcribing secre-
taries.

VIII. REPORT OF THE PRESIDENT:

Doctor Jack L. Richardson presented his re-
port and it was referred to Reference Commit-
tee No. I. (A copy of the report is attached and
made a part of these minutes).

IX. REPORT OF THE PRESIDENT-ELECT:
Doctor Arnold G. Nelson presented his re-
port and it was referred to Reference Commit-
tee No. I. (A copy of the report is attached and
made a part of these minutes).

X. REPORT OF THE CHAIRMAN OF THE
BOARD:

Doctor John McIntyre presented information
contained in the Board of Trustees Report and
the Board’s Supplemental Report. Both reports
were referred to Reference Committee No. I.
(Copies of the reports are attached and made a
part of these minutes).

XI. SECRETARY -TREASURER’S REPORT:

Doctor Stone stated that this report will be

deferred until the Closing Session of the House
of Delegates. The Secretary-Treasurer’s Report
was referred to Reference Committee No. I. (A
copy of the report is attached and made a part
of these minutes).

XII. NOMINATIONS FOR ELECTIONS:
Doctor Stone announced the House would re-
cess for ten minutes for all Trustee Districts
XI, XII, XIII and XIV to caucus.

XIII. NOMINATIONS:

The House was declared open for the nomi-
nations for the position of PRESIDENT-
ELECT (One year term of office).

Orange M. Welborn, MD, Ada, was nomi-
nated by David Ramsay, MD, Ada.

Roger J. Reid, MD, Ardmore, was nominated
by Frank W. Clark, MD, Ardmore.

Nominations were declared closed.

Nominations were declared open for the pos-
ition of VICE-PRESIDENT (One year term of
office).

William M. Leebron, MD, Elk City, was
nominated by Ed Calhoon, MD, Beaver.

Nominations were declared closed.

Nominations were declared open for the pos-
ition of SECRETARY-TREASURER (Two year
term of office).

Haven W. Mankin, MD, Oklahoma City, was
nominated by Roger Reid, MD, Ardmore.

Nominations were declared closed.

Nominations were declared open for the pos-
ition of DELEGATE TO THE AMA (Two year
term of office).

Ed L. Calhoon, MD, Beaver, was nominated
by John X. Blender, MD, Cherokee.

Nominations were declared closed.

Nominations were declared open for the pos-
ition of ALTERNATE DELEGATE TO THE
AMA. (Two year term of office).

M. Joe Crosthwait, MD, Midwest City, was
nominated by Kent Braden, MD, Oklahoma
City.

Nominations were declared closed.

Nominations were declared open for TRUS-
TEE AND ALTERNATE TRUSTEE for the
following Trustee Districts (three year term of
office):

DISTRICT XI:

Reporting on the caucus of representatives
from District XI, the following nominations
were made:

Beryl R. McCann, MD, Durant, was nomi-
nated for the position of Trustee.

Thomas E. Rhea, MD, Idabel, was nomi-
nated for the position of Alternate Trustee.
DISTRICT XII:

Orange M. Welborn, MD, Ada, nominated
Frank W. Clark, MD, Ardmore, for the position
of Trustee.

Clarence P. Taylor, MD, Ada, was nominated
for the position of Alternate Trustee.
DISTRICT XIII:

Samuel Jack, MD, Lawton, nominated Paul
N. Vann, MD, Lawton, for the position of Trus-
tee.

A. C. Roberson, MD, Anadarko, was nomi-
nated for the position of Alternate Trustee.
DISTRICT XIV:

Fred W. Sellers, MD, Mangum, nominated
Lowell N. Templer, MD, Altus, for the position
of Trustee.

Fred W. Sellers, MD, Mangum, was nomi-
nated for the position of Alternate Trustee.

Journal / July 1975 / Volume 68

243

news

XIV. ADDRESS FROM THE PRESIDENT
OF THE AMERICAN MEDICAL ASSOCIA-
TION:

Doctor Malcolm Todd, President of the
American Medical Association, addressed the
House of Delegates and brought greetings. He
stated that each physician should and must pre-
serve the private practice of medicine in the
United States of America.

Doctor Todd stated that the AMA has sev-
eral legal actions in progress at the pres-
ent time. Some of the actions include health
planning bills^ actions on federal regulations
regarding utilization review, those involving
the Anti-Substitution Bill on drugs, etc.

Doctor Todd expressed his appreciation to
the Oklahoma physicians for their unified
membership support in previous years.

Doctor Jack L. Richardson presented a plaque
of appreciation to Doctor Todd on behalf of
the Oklahoma State Medical Association.

XV. INTRODUCTION OF COUNCIL AND
COMMITTEE REPORTS AND RES-
OLUTIONS:

Doctor Stone advised the Delegates that in
order to save time, a list of reports and reso-
lutions is included in their portfolios, and an
item by item introduction would not be neces-
sary. Doctor Stone also advised the Delegates
that "late resolutions” have been approved for
introduction by the Board of Trustees in accor-
dance with the Bylaws.

XVI. ANNOUNCEMENT:

Doctor Stone stated that the reference com-
mittee hearings will be held at 8:00 a.m., April
24th.

XVII. NECROLOGY REPORT:

The Vice-Speaker of the House of Delegates,
Jack Fetzer, MD, read the Necrology Report.
(A copy of the report is attached and made a
part of the minutes).

XVIII. ADJOURNMENT OF OPENING
SESSION: /

The Opening Session of the House of Dele-
gates was adjourned at 5:00 p.m.

NECROLOGY REPORT

Alfred T. Baker, MD, Durant

James C. Brogden, MD, Tulsa

Elizabeth M. Chamberlin, MD, Bartlesville

James B. Eskridge, Jr., MD, Oklahoma City

Emry G. Hyatt, MD, Tulsa

William A. Hyde, MD, Durant

244

Emery W. King, MD, Bristow

Robert L. Loy, MD, Oklahoma City

Thomas J. McGrath, MD, Sayre

George H. Miller, MD, Tulsa

Charles J. Roberts, MD, Enid

Mary V. S. Sheppard, MD, Oklahoma City

Harlan K. Sowell, MD, Oklahoma City

C. Riley Strong, MD, El Reno

Noble F. Wynn, MD, Edmond

CLOSING SESSION

I. CALL TO ORDER:

The Closing Session of the 69th Annual
Meeting of the House of Delegates was called
to order by the Speaker, S. N. Stone, MD, at
9:15 a.m., April 25, 1975, in the Lincoln Plaza
Inn, Oklahoma City.

II. REPORT OF THE CREDENTIALS COM-
MITTEE:

Jack D. Fetzer, MD, Chairman of the Cre-
dentials Committee, announced a quorum pre-
sent.

III. INVOCATION:

Rex Kenyon, MD, Oklahoma City, delivered
the invocation.

IV. INTRODUCTION OF SPECIAL
GUESTS:

Doctor Stone introduced Mrs. James Man-
ning from Marietta, Georgia, President of the
Woman’s Auxiliary to the Southern Medical
Association and Mrs. Erie E. Wilkinson from
Nashville, Tennessee, President-Elect of the
Woman’s Auxiliary to the AMA. Both brought
greetings to the OSMA House of Delegates.

V. REPORTS OF REFERENCE COMMIT-
TEES:

All reports considered by the House of Dele-
gates are attached and approved and made a
part of these minutes.

REPORT OF REFERENCE COMMITTEE
NO. Ill:

Presented by: Jack Parrish, MD, Seminole,
Chairman

Mr. Speaker and Members of the House of
Delegates, your reference committee gave
careful consideration to the items referred to it
and makes the following report:

Item I: Report of the Council on Socioeconomic
Activities:

Mr. Speaker, your committee considered this
report and wishes to commend the members of
the council, and specifically the members of the
OSMA Peer Review Committees, for their
work and recommends that this report be
adopted as written.

Oklahoma State Medical Association

Mr. Speaker, I move the adoption of this re-
port. The motion was seconded and it carried.
Item II: Report of the Council on Continuing
Medical Education:

Mr. Speaker, your committee feels that it
cannot overstate the importance of continuing
medical education to the practice of medicine.
The actions and activities of this council are to
be commended.

Mr. Speaker, I move the adoption of this re-
port as written. The motion was seconded and it
carried.

Item III: Report of the Medical Center Liaison
Committee:

Mr. Speaker, the activities of this committee
during this past year deserve special consid-
eration. The statewide public relations cam-
paign launched to support the Oklahoma
Health Sciences Center has resulted in a better
understanding of the center’s operation and its
needs for support by the practicing medical
community.

Recommendation No. 2 should be deleted
from this report. Resolution No. 15, considered
by Reference Committee No. II speaks to this
issue.

Mr. Speaker, I move the adoption of this re-
port as amended. The motion was seconded and
it carried.

Item IV: Report of the Financial Aid to Educa-
tion Committee:

Mr. Speaker, your committee recommends
that the functions of this committee be more
widely publicized to association members.

Mr. Speaker, I move the adoption of this re-
port as written. The motion was seconded and it
carried.

Item V: Report of the Council on Public Health:

Mr. Speaker, your reference committee
wishes to commend the members of the council
and the various committees of the council for
their activities during the past year.

Mr. Speaker, I move the adoption of this re-
port as written. The motion was seconded and it
carried.

Item VI: Resolution No. 4:

Mr. Speaker, this resolution reiterates the
recommendations made in the report of the
Committee on Emergency Medical Services
contained in the report of the Council on Public
Health. Both the committee report and this
resolution deserve the support of the OSMA.

Mr. Speaker, I move the adoption of this re-
solution. The motion was seconded and it car-
ried.

Journal / July 1975 / Volume 68

Item VII: Resolutions No. 5, 10, and 13:

Mr. Speaker, your reference committee con-
sidered Resolutions No. 5, 10 and 13 together.
It was felt that the subject matter of these
three resolutions was compatible.

After carefully considering all of the tes-
timony it received on Thursday morning, it is
the recommendation of your committee that
these three resolutions be replaced by the fol-
lowing substitute resolution:

WHEREAS, the published regulations ap-
pearing in the Federal Register on November
29, 1974 implementing Utilization Review are
inconsistent with good patient care, infringe on
the doctor-patient relationship, threaten the
confidentiality of that relationship, promul-
gate the deterioration of quality medical care,
pose the potential threat of closing many hos-
pitals and threaten our patients with possible
loss of hospital privileges and financial assis-
tance, and

WHEREAS, Peer Review and Utilization
Review has been traditionally performed by
the profession to assure quality medical care,
not cost control, and is best handled at the local
level so that it can take into consideration local
problems, and

WHEREAS, any nationwide method of
Utilization Review must necessarily ignore
such local problems and cannot be accurately
varied into size of hospital facility or medical
staff, and

WHEREAS, any such national scheme will
result only in a rationing of health care ser-
vices to patients, therefore be it
RESOLVED, that the physicians of the State
of Oklahoma vigorously support the American
Medical Association’s lawsuit against these
onerous regulations, and, therefore be it
RESOLVED, that the physicians of the State
of Oklahoma will continue Utilization Review
and Peer Review on an individual hospital
basis, and will not participate in Utilization
Review as outlined in the above cited reg-
ulations, and

WHEREAS, the Oklahoma State Medical
Association recognizes that this stance will re-
quire a public relations campaign to inform the
general public as to the necessity for this posi-
tion, now therefore be it

RESOLVED, that the House of Delegates of
the Oklahoma State Medical Association au-
thorize the OSMA Board of Trustees to insti-
tute a voluntary assessment to establish an
adequate public relations campaign budget in

245

news

the event that the Federal Court upholds the
regulations as currently published, and there-
fore be it further

RESOLVED, that the Oklahoma State Med-
ical Association seek the broadest possible base
of support in such a campaign by contacting
other medical associations throughout the
United States.

Mr. Speaker, I move the adoption of this sub-
stitute resolution in place of Resolutions 5, 10
and 13. Doctor Carpenter seconded the motion.

The House was opened for discussion. Doctor
Crosthwait made a motion that discussion on
this topic be limited to three minutes. The mo-
tion was seconded and it carried.

After considerable discussion on this item,
Doctor R. W. Goen, Tulsa, moved that the word
" voluntary ” be stricken from the first resolve
and the word rr mandatory ” be put in its place.
The motion was seconded.

An amendment was made to the motion that
the mandatory assessment be not under $50 per
person.

After further discussion, Doctor Nelson called
for the question on the amendment. Doctor
McIntyre seconded the amendment.

The amendment for a mandatory assessrnent
of not under $50 was opposed.

Doctor James Eskridge requested that the
reference committee consider editorial changes
on page 3, paragraph 1 to read as follows:

"Whereas, the published regulations appear-
ing in the Federal Register on November 29,
1974 implementing Utilization Review are in-
consistent with good patient care, infringe on
the doctor-patient relationship, constitute un-
solicited and therefore unethical consultation,
threaten the confidentiality of that rela-
tionship, promulgate the deterioration of qual-
ity medical care, pose the potential threat of
closing many hospitals and threaten our pa-
tients with possible loss of hospital privileges
and financial assistance, and . .

Doctor Berry, Kingfisher, made a motion
that the last resolve be changed to read as fol-
lows:

"Resolved, that the Oklahoma State Medical
Association seek the broadest possible base of
support in such a campaign by inviting cooper-
ation by other state medical associations
throughout the United States.”

Doctor Braden called for the question on the
editorial change. The editorial change was sec-
onded and carried.

The vote was called on the amendment made
in the last resolve. The motion was seconded 1
and it carried.

The question was called for the acceptance of
the substitute motion. The motion was seconded
and carried. There were two no votes.

Item No. VIII: Resolution No. 9:

Mr. Speaker, your committee feels that this
resolution is a restatement of the association s
current position. Mr. Speaker, I move the adop-
tion of this resolution as written. The motion
was seconded and carried.

Item No. IX: Resolution No. 11:

Mr. Speaker, it was the understanding of
your committee that the American Medical
Association is in the process of establishing an
office similar to the one called for in Resolution
No. 11. Until such time as that office is
clarified and its functions delineated, your
committee feels that any action in this regard
by your state medical association should be
postponed.

Mr. Speaker, 1 move that Resolution No. 11 be
not adopted. The motion was seconded and it
carried. There was one no vote.

Item No. X: Resolution No. 14:

Mr. Speaker, after carefully considering the
testimony your committee received on this res-
olution, the committee came to the conclusion
that perhaps it is not the ethics of the situa-
tion, but the Oklahoma law that should be
changed. Therefore, your committee recom-
mends that the section of the Oklahoma sta-
tute cited in this resolution be studied by ap-
propriate legal counsel to see if such a change
should be implemented.

Mr. Speaker, I move that Resolution No. 14 be
not adopted.

Doctor Jack Parrish made a substitute mo-
tion and the resolve should read as follows:
"Resolved, that the Report of the Judicial
Council of the AMA be waived until such time
that the Oklahoma statute is changed or
waived.”

The motion was seconded and carried on the
substitute motion.

Item No. XI: Resolution No. 16:

Mr. Speaker, your committee considered this
resolution very carefully. While the committee
admired the philosophy outlined in this res-
olution, the resolves it contains are so far
reaching and encompass so many facets of the
social, economic, and political aspects of the
practice of medicine as to make it untenable in
this form. Many of the resolves are being han-

246

Oklahoma State Medical Association

died specifically by the reports of the asso-
ciation’s various councils, committees and
other resolutions.

Your committee wishes to specifically com-
mend Kent Braden, MD, for so eloquently out-
lining the philosophy that we all would like to
espouse. However, an attempt to encompass it
all in one omnibus resolution simply is un-
workable.

Mr. Speaker, I move that Resolution No. 16 be
not adopted. The motion was seconded and car-
ried.

Mr. Speaker, I would like to extend my
thanks to the reference committee and to those
who came to give testimony. I would also like
to thank Ed Kelsay and the staff.

Mr. Speaker, I move the adoption of this re-
port (is a whole. The motion was seconded and
it carried.

The House of Delegates recessed for ten
minutes.

REPORT OF REFERENCE COMMITTEE
NO. II:

Presented by: Robert Shepard, MD, Tulsa,
Chairman

Mr. Speaker and Members of the House of
Delegates, Reference Committee No. II has
carefully considered the items which were re-
ferred to it and submits the following report:
Item I. Report of the Council on Professional
and Intervocational Relations:

Mr. Speaker, your Committee considered
this report in its entirety and wishes to com-
mend the Chairman and his committees for the
fine effort expended on behalf of the Associa-
tion. Members should recognize and be aware
that cordial relations with others involved in
medical care services are essential and bene-
ficial to the Association.

RECOMMENDA TION:

Mr. Speaker, we recommend approval of the
Report of the Council on Professional and In-
tervocational Relations.

Mr. Speaker, I move the adoption of this por-
tion of the Report. The motion was seconded
and carried.

Item II: Report of the Council on Public Policy:

Mr. Speaker, your Committee considered
this report in its entirety. We would like to
make note of the report of the State Legislative
Committee. Last year the Delegates approved
a recommendation that the Association pur-
chase or lease an automatic typewriter. As in-
dicated in the report, the equipment is installed
and has been of significant help to the com-

Journal / July 1975 / Volume 68

mittee and the Association in meeting its
communication needs. The Delegates can take
pride in the decision made last year. We also
mention the fact that the committee has
utilized the services of outside help in a special
case when it was deemed necessary. Barton
Carl, MD, Chairman of the Committee tes-
tified about the success of this approach and
recommended that this technique be employed
when necessary and approved by the Trustees.
RECOMMENDA TION:

Mr. Speaker, we recommend approval of the
Report of the Council on Public Policy.

Mr. Speaker, 1 move the adoption of this por-
tion of the report. The motion was seconded and
it carried.

Item III: Resolutions No. 7 and 8:

Both Resolutions 7 and 8 deal with insur-
ance companies and the policies they use to
underwrite the risks they insure. Resolution
No. 7 expresses concern over the retrospective
review of patients’ medical records after claims
have been filed. Resolution No. 8 addresses it-
self to the problem of the ’'pre-existing illness”
clause in insurance policies that results in the
denial of some claims. Testimony cited the
problems of patients who, after paying pre-
miums for years, find that specific illnesses are
not covered on the grounds of being "pre-
existing.” Your Reference Committee ex-
presses concern over the less than honorable
practices of some insurance companies but we
recognize that certain information and inves-
tigations are necessary to the insurance indus-
try. We suggest that Resolutions 7 and 8 be
referred to the Council on Insurance with in-
structions to study these problems and make
recommendations to the Board of Trustees for
implementation, and that a progress report be
made to the House next year.

RECOMMENDA TION:

Mr. Speaker, we recommend that Resolutions
7 and 8 be referred to the Council on Insurance.

Mr. Speaker, I move the adoption of this por-
tion of the report. The motion was seconded and
it carried.

Item No. IV: Resolution No. 15:

Resolution No. 15 requests that a Committee
be appointed to study the admissions policy of
the OU College of Medicine. The Committee
was informed that a Senate Joint Resolution
(SJR 22) has passed the Oklahoma Senate that
would legislate the composition of the Board of
Admissions. The Committee was also advised
that authors of the bill have under consid-

247

news

eration amendments that would require mem-
bership of the Board of Admissions to represent
each of the six congressional districts. Two
physicians would be selected from each dis-
trict. They would be appointed by the State
Medical Association with concurrence of the
local medical societies. Your Reference Com-
mittee listened to considerable testimony on
this issue and feels that it is not in the best
interest of the school for the Legislature to dic-
tate the composition of the Admissions Board.
However, it is obvious that a great number of
physicians in the State, in addition to our polit-
ical leaders and the lay public, do not under-
stand the admissions policies of the OU College
of Medicine. We feel that a comprehensive
study with accompanying public relations and
dissemination of information to the physicians
of Oklahoma would be of great benefit to the
school.

RECOMMENDA TION:

Mr. Speaker, your Reference Committee re-
commends the adoption of Resolution 15. The
motion was seconded and it carried.

Mr. Speaker, I recommend the adoption of
this portion of the report. The motion was sec-
onded and it carried.

Mr. Speaker, 1 recommend the adoption of
Reference Committee Report No. II as a whole.
The motion was seconded and it carried.
Robert M. Shepard, Jr., MD, Tulsa, Chairman
John A. Blaschke, MD, Oklahoma City
E. C. Yeary, MD, Ponca City
Frank Adelman, MD, Enid
Irwin H. Brown, MD, Oklahoma City
James S. Jones, MD, Duncan
George M. Brown, Jr., MD, McAlester
Samuel C. Jack, MD, Lawton
David Bickham, Staff

REPORT OF REFERENCE COMMITTEE
NO. I

Presented by: Arthur F. Elliott, MD, Okla-
homa City, Chairman

Mr. Speaker and Members of the House of
Delegates, your reference committee gave
careful consideration to the items referred to it
and makes the following report:

Item I: Report of the President:

Your reference committee recommends
adoption of the Report of the President, and
commends Doctor Richardson for his efforts on
behalf of the association during the past year.

Mr. Speaker, I move the adoption of this por-

248

tion of the report. The motion was seconded and
it carried.

Item II: Report of the President-Elect:

Doctor Arnold G. Nelson, incoming president
of the association, set a worthy precedent by
addressing the House of Delegates, a practice
which your reference committee hopes will be
continued in future years. Doctor Nelson made
two recommendations in his report, and re-
quested delegates’ action, as follows:

Recommendation No. 1:

"I would like to recommend that our House
of Delegates approve upcoming meetings of
the Oklahoma Medical Summit in Okla-
homa City for at least the next three years.
Many times, on the short notice we have
had, it is somewhat difficult to obtain some
of the speakers and some of the commit-
ments that we coi^ld have otherwise had,
had we had a longer notice.”

Recommendation No. II:

"I recommend that your new president be
allowed to appoint an Ad Hoc Committee to
study the committee structure of our
association, and that the Ad Hoc Committee
be chaired by the new president-elect who-
ever he may be. Councils and committees
should be studied and defined.”

Your reference committee concurs in both of
the preceding recommendations, and recom-
mends their adoption by the House of Dele-
gates. It is clear that physical arrangements
for medical conventions need to be made well
in advance, and that prominent scientific lec-
turers cannot be obtained on short notice. Sec-
ondly, during this dynamic era of change,
which can have significant impact on medical
practice, it is imperative that the OSMA con-
tinually assess its priorities and devote its
financial and personnel support to those com-
mittee activities which have the greatest im-
port. An assessment of our committee struc-
ture is certainly in order, and Doctor Nelson
shows wisdom in recognizing this need.

Mr. Speaker, I move the adoption of this por-
tion of the report. The motion was seconded and
it carried.

Item III: Report of the Secretary-Treasurer:

The Secretary-Treasurer has presented to
the House a forthright assessment of the
economic condition of the OSMA, and has ob-
served that present annual dues of $120 annu-
ally will not likely sustain current activities

Oklahoma State Medical Association

for another year without the prospect of deficit
spending. He has illustrated that average dues
for state medical associations across the coun-
try are $140 annually, and has isolated the
dues structures of states comparable to Okla-
homa, most of which have annual dues in ex-
cess of these presently charged OSMA mem-
bers. The Secretary-Treasurer, Doctor Haven
Mankin, deferred this problem to the judgment
of the House of Delegates, and your reference
committee will respond to this matter in Item
IV which follows. Your reference committee
recommends the adoption of the Report of the
Secretary-Treasurer.

Mr. Speaker, I move the adoption of this por-
tion of the report.

A substitute motion was made to table this
item until after the luncheon. The motion was
seconded and carried.

The closing session of the OSMA House of
Delegates recessed at 11:50 a.m. for lunch.

The closing session of the OSMA House of
Delegates resumed at 1:40 p.m.

Item IV: Board of Trustees Report and Supple-
mental Report:

The annual report of the OSMA Board of
Trustees illustrates responsible activity in a
variety of areas of interest during the past
organizational year, and the adoption of this
report is recommended by your reference com-
mittee.

In the Supplemental Report of the Board of
Trustees, a report of actions taken by the
Board during this annual meeting, the Board
took note of the Report of the Secretary-Treas-
urer concerning association finances. The
Trustees observed that the association cannot
operate at the same level without experiencing
a deficit, especially if staff salaries are to be
increased and if staff capabilities are to be ex-
panded to meet expanding challenges. In its
report, the Board took the position that the
OSMA cannot be permitted to deteriorate in
any fashion, and requested that the House of
Delegates adopt a dues increase for 1976 in an
amount not less than $20 annually.

Your reference committee, after receiving
testimony from a number of witnesses, concurs
with the Board of Trustees that a 1976 dues
increase is necessary and desirable. Recom-
mendations from the witnesses ranged from a
minimal $20 per year increase to as high as
$55 annually. Since the association collects
dues on a calendar year basis but operates on a
fiscal year basis of June 1 through May 31,

Journal / July 1975 / \tolume 68

only five-twelfths of the new dues income can
be allocated to the fiscal year ending May 31,
1976. Thus, a $20 dues increase would produce
only about $16,000 in new income for the next
fiscal year, but would produce approximately
$40,000 the succeeding fiscal year. Your refer-
ence committee believes that this minimal in-
crease would simply be maintaining the status
quo and would not permit any great expansion
of association productivity.

Conversely, a $55 increase, in the opinion of
your reference committee, would not be popu-
larly received by the membership at this time.

Therefore, your reference committee strong-
ly recommends that OSMA dues for 1976 be
increased by $30 to a total annual dues of
$150 annually. This amount would produce
approximately $25,000 in new income for the
next fiscal year and would generate as much as
$60,000 for the following fiscal year.

Your reference committee feels constrained
to observe that major issues currently confront
the association, such as the matter of non-
participation in federalized utilization review
regulations. A strong stance against these reg-
ulations will present a major public relations
problem to the association which cannot be
sustained by any reasonable dues increase.
Your committee, therefore, observes to the
House of Delegates that major confrontations
against onerous federal regulations will un-
doubtedly require a special assessment in
order to develop a successful response to puni-
tive federal actions which may be taken
against the profession.

Mr. Speaker, I move the adoption of this por-
tion of the report. The motion was seconded and
it carried.

Item V: Resolutions 2, 3 and 6:

These resolutions relate to the question of
unified or voluntary membership in the
American Medical Association. Because of
their similarity in purpose, your reference
committee considered these resolutions
collectively.

Perhaps due to the location of the reference
committee hearing room, your committee re-
ceived only minimal testimony with respect to
this very important issue. The number of wit-
nesses appearing to speak on this question
were so few that your committee did not feel
that it could make an honest assessment of the
attitude of the House of Delegates. Indeed,
within the committee membership itself, there
was an even division as to the repeal of re-

249

news

quired membership in the AMA. For these
reasons, your reference committee feels that
the matter must be referred back to the entire
House of Delegates for discussion and decision.

In reviewing the three resolutions on this
subject, your committee favors resolution No. 3
as submitted by the Tulsa County Medical Soc-
iety, although it feels that the second "Where-
as” beginning on line 4 refers to a referendum
which was not completely unbiased.

Therefore, your reference committee recom-
mends that a substitute resolution be adopted
by the House of Delegates which incorporates
lines 8 through 14 of resolution No. 3, to wit:

"RESOLVED, that the OSMA House of Dele-
gates, acting at the annual meeting of April
23-26, 1975, approve appropriate amend-
ments to the bylaws of the Oklahoma State
Medical Association to delete the require-
ments that its members be members of the
American Medical Association; and be it
further

"RESOLVED, that the Oklahoma State
Medical Association urge its members to vol-
untarily be members of the American Medi-
cal Association.”

If it is the desire of the House of Delegates to
adopt the preceding substitute resolution, then
your reference committee recommends that the
amendments contained in the report of the
Constitution and Bylaws Committee be
utilized as instruments to effect the change in
policy toward AMA dues.

Mr. Speaker, we recommend that this issue
now be opened for House consideration. The
motion was seconded and it carried.

After considerable discussion on this subject,
Doctor M. K. Braly called for the question and
made a motion that the Speaker require a secret
ballot. The motion was seconded and it carried.

The vote for mandatory membership in the
AMA carried with 46 yes votes and 32 no votes.
Item VI: Resolution No. 1:

This resolution, submitted by the Oklahoma
County Medical Society has the laudable pur-
pose of endorsing a standardized health insur-
ance claim form. It is the opinion of the com-
mittee that the form referred to in the resolu-
tion as the "American Medical Association
Uniform Claim Form” is a form which is cur-
rently being perfected by the AMA, the Na-

tional Association of Blue Shield Plans, the
Health Insurance Council and the Bureau of
Health Insurance. However, since an informed
representative of the Oklahoma County Medi-
cal Society was not present for the hearing, and
since the committee was not possessed of a copy
of the form in question, it was not felt to be
wise to recommend passage of this resolution.
The current OSMA policy is to endorse the
Health Insurance Council COMB-I form, a
form which is in actual use and which has been
widely accepted by insurance companies.

Therefore, your committee recommends dis-
approval of Resolution No. 1 due to insuffic-
ient evidence as to the existence of the form in
question.

Mr. Speaker, I move the adoption of this por-
tion of the report. The motion was seconded and
it carried.

Item VII: Report of the Constitution and Bylaws
Committee:

This report delineates amendments to the
bylaws which would have the effect of making
AMA dues voluntary; as mentioned in Item V
above, although, the Constitution and Bylaws
Committee adopted no position on the issue.

In addition, this report corrects oversights in
the Constitution and recommends amend-
ments to clarify the OSMA’s relationship with
"Oklahoma Medical Summit.”

Your reference committee recommends adop-
tion of this report.

Mr. Speaker, I move the adoption of this por-
tion of the report. The m otion was seconded and
it carried.

Item VIII: Resolution No. 12:

This resolution has the purpose of providing
that the AMA discontinue free distributions of
all publications except JAMA, and that sub-
scription prices be established by the AMA for
other publications if feasible; further it rec-
ommends that fiscally unsound publications of
the AMA be abandoned.

The second "Whereas” on line 5 and the third
"Whereas” on line 9 contained statements
which your reference committee cannot verify.
In fact, the profit and loss picture of all AMA
publications is presently under study by a spe-
cial committee of the AMA House of Delegates
in cooperation with a management consultant
firm, and the findings of these activities are
not available at this time.

Therefore, your reference committee recom-
mends the adoption of the following Resolution
No. 12, as amended:

"WHEREAS, the American Medical Associa-

250

Oklahoma State Medical Association

tion has found itself in a financially embar-
rassing position and, therefore, has found it
necessary to assess AMA members $60;
therefore be it

"RESOLVED, that the Oklahoma State
Medical Association urge the American
Medical Association to discontinue, im-
mediately, free distribution of all publica-
tions, except for JAMA; and be it further

"RESOLVED, that the AMA establish a sub-
scription price that will pay for its other
publications, or, if such a subscription price
is not feasible, that it discontinue, im-
mediately, the publication of specialty jour-
nals, Prism, and all other magazines, leaf-
lets, and brochures not fiscally sound.”

Mr. Speaker, I move the adoption of this por-
tion of the report.

After consideration of this item, the resolu-
tion was editorially amended to read as fol-
lows:

"WHEREAS, the American Medical Associa-
tion has found itself in a financially embarras-
sing position and, therefore, has found it neces-
sary to assess AMA members $60; therefore be
it

"RESOLVED, that the Oklahoma State Med-
ical Association urge the American Medical
Association to discontinue, immediately, free
distribution of all publications, except for
JAMA, and items of news or organizational
interest; and be it further
"RESOLVED, that the AMA establish a sub-
scription price that will pay for those other
publications previously distributed as a benefit
of membership, or, if such a subscription price
is not feasible, that it discontinue, immediate-
ly, the publication of such specialty journals,
and all other magazines, leaflets, and
brochures not fiscally sound.

Mr. Speaker, I move the adoption of this por-
tion of the report as editorially amended. The
motion was seconded and it carried.

Item IX: Report of the Council on Insurance:
This report represents an assessment of the
various insurance programs sponsored by the
association on behalf of its membership. Your
reference committee recommends approval of
this report, and extends its appreciation for the
splendid insurance program being furnished to
OSMA members by the Council.

Mr. Speaker, I move the adoption of this por-
tion of the report. The motion was seconded and
it carried.

Mr. Speaker, I move the adoption of this re-
Journal / July 1975 / Volume 68

port as a whole. The motion was seconded and
it carried.

Arthur F. Elliott, MD, Oklahoma City, Chair-
man

J. William McDoniel, MD, Chickasha

Elvin M. Amen, MD, Bartlesville

Charles Tefertiller, MD, Altus

Rollie Rhodes, Jr., MD, Tulsa

Robert A. McLauchlin, MD, Oklahoma City

Jack L. Berry, MD, Okarche

Don Blair, Staff

VI. PRESENTATIONS:

An AMPAC Award was awarded to Doctor
Ed L. Calhoon, former Chairman of OMPAC
and Doctor Kent Braden, present Chairman of
OMPAC. The award was presented by Doctor
Rex Kenyon, Member of the Board of Directors
of AMPAC.

An Award of Appreciation was given to Doc-
tor Howard Keith by Doctor Jack L. Richard-
son on behalf of his efforts on the OSMA Peer
Review Committee.

VII. ELECTION OF OFFICERS:

The following Officers were elected:

Orange M. Welborn, MD, Ada, was elected to

the office of President-Elect.

William M. Leehron, MD, Elk City, was
elected to the office of Vice-President.

Haven W. Mankin, MD, Oklahoma City, was
elected to the office of Secretary-Treasurer.

Ed L. Calhoon, MD, Beaver, was elected to
the office of AMA Delegate.

M. Joe Crosthwait, MD, Midwest City, was
elected to the office of AMA Alternate Dele-
gate.

A motion was made to accept these appoint-
ments by acclamation. The motion was second-
ed and it carried.

VIII. ELECTION OF TRUSTEES AND AL-
TERNATE TRUSTEES:

The following Trustees and Alternate Trust-
ees were elected by acclamation:

Trustee District XI: Atoka, Bryan, Coal, Choc-
taw, McCurtain & Pushmataha Counties
Trustee: B. R. McCann, MD, Durant
Alternate: Thomas E. Rhea, MD, Idabel
Trustee District XII: Carter, Love, Marshall,
Garvin, Johnston, Murray & Pontotoc Coun-
ties

Trustee: Frank W. Clark, MD, Ardmore
Alternate: Clarence P. Taylor, MD, Ada
Trustee District XIII: Caddo, Comanche, Cot-
ton, Tillman, Grady, Jefferson and Stephens
Counties

Trustee: Paul N. Vann, MD, Lawton
Alternate: A. Craig Roberson, MD, Anadarko

251

news

Trustee District XIV: Greer, Harmon, Jackson,
Kiowa & Washita Counties

Trustee: Lowell N. Templer, MD, Altus

Alternate: Fred W. Sellers, MD, Mangum

A motion was made to elect the trustees and
alternate ti'ustees by acclamation. The motion
was seconded and it carried.

IX. ANNOUNCEMENT:

Doctor Stone introduced Doctor Kent Bra-
den, Chairman of the OMPAC Board of Direc-
tors, who made a plea for 100% OMPAC mem-
bership and for sustaining memberships.

Doctor McIntyre stated that the Board of
Trustees would meet immediately following
the closing session of the House of Delegates.

X. ADjpURNMENT:

The 69th closing session of the House of Del-
egates adjourned at 3:05 p.m.

Recorded by Betty Lyles

Report of the
PRESIDENT
April 23, 1975
( APPROVED )

Mr. Speaker; Fellow Members of the House of
Delegates:

Being allowed to serve you this past year as
President of this great State Medical Associa-
tion is an honor for which I am deeply grateful.
The cooperation, assistance and kindness I
have received in carrying out my obligations
to this office have been a delight. Achieve-
ment would not have been possible without this
fine support and I take this opportunity to
thank you for it, one and all.

Upon assuming office last May, I at that
time had plans to return from the upcoming
June AMA Meeting and establish a wide-
spread publicity program to inform our state
citizens of the drawbacks of the PSRO Program
as promulgated by HEW. My esteemed col-
league, Joe Crosthwait, Chairman of our Pub-
lic Policy Council, and I had previously talked
at some lengths about this. Remember that not
only did we have the consensus of our State
Membership behind our efforts, but had se-
cured commitments from seven of our national
legislators. In addition, we felt the tenor of the
previous meeting at Anaheim was a strong
confirmation of our plan. Lo and behold,
Oklahoma’s surprise at Chicago when the
House of Delegates ratified by a wide margin
the plan of the Board of Trustees of the AMA to
approve PSRO. This was embarrassing to

252

Oklahoma because we had assured our own
Congressmen, as well as other legislators in
Washington, that medicine was strongly op-
posed to this program. The House of Delegates
acquiesced to the Board of Trustees, however,
and endorsed PSRO. It is sad that not one of
the modifications the Board of Trustees had
suggested has ever been granted. It is a credit
to Oklahoma’s delegation that they never
waivered in their stand, while about them
state after state, many of whom had made
written or oral commitments to hold strong
against government intervention, capitulated.
Oklahoma’s solid stand is evidence of its philo-
sophic fidelity.

Thereupon, your State Association turned its
effort to critical problems at home. Our Medi-
cal School and Health Sciences Center were in
serious difficulty and at a stalemate with the
Legislature. We felt that our State Association
could perhaps aid them when they could not do
it for themselves. I appointed a tenacious, ag-
gressive, public-spirited doctor as Chairman of
the Medical School Liaison Committee, C. S.
Lewis of Tulsa. Together he and I spent count-
less hours with the University President, the
Acting Provost, Acting Dean, Legislators, Re-
gents, candidates for Governor and medical
school faculty. Fine cooperation was obtained
from all. Our membership contributed to the
development of a sound-slide program which
was taken throughout the state, some twenty-
five showings being given. The rest is history!
The Medical School has a new Provost and is
better financed now than ever before. Full fi-
nancing for the coming year has been assured.
Doctor Lewis and his committee — and you —
are deserving of high praise for this concen-
trated effort leading to success.

In addition to the gains just described, there
are also Family Practice Residencies in Okla-
homa City and Tulsa and a satellite program is
being planned for other areas of the state, the
first of which is to be at Enid. The Tulsa Medi-
cal Branch is underway and off to a good start.

Our combined annual meeting has proved a
success with a larger attendance than has ever
been experienced before, thanks to fine
cooperative efforts of the three component or-
ganizations.

Your State Association has purposely been
one of the very last to apply for a PSRO Plan-
ning Grant, but this has not deterred Doctor
Hillard Denyer, Chairman of the Oklahoma
Foundation for Peer Review, from working dil-
igently with his committee in anticipation of

Oklahoma State Medical Association

the possible ultimate necessity. Meanwhile, we
have had perhaps an even more onerous gov-
ernment program dropped on us in the way of
P.L. 93-641, the Health Planning Bill, that
would tell us where, when and how to practice.
HEW attempted to force on us pre-hospital cer-
tification for our patients and then utilization
review, the latter so lacking in circumspection
that no thought had been given to the fact that
smaller hospitals could not possibly comply
with its regulations. These, of course, will be
only two of the innumerable defective regula-
tions that will be foisted upon the profession
and the public. It is to the great credit of the
AMA that it has filed suit challenging in court
constitutionality of Utilization Review, while
public reaction forced a delay in implementing
pre-hospital certification. Please note, how-
ever, that Mr. Weinberger has not granted
permanent relief from such pre-hospital cer-
tification, only agreeing to a delay.

Our national organization has found itself in
economic difficulties, this being the fifth year
in six that has ended with a marked deficit.
With the insistence of certain alarmed and in-
trepid groups and members, there has been an
attempt to economize by eliminating certain
programs in order to become fiscally sound.
Again your State Delegation was active in re-
questing financial responsibility, although not
without being considered audacious by the
Board of Trustees. The main point is, the effort
was successful. Just last month, the Board of
Trustees of AMA approved a planning program
including "possible changes in the organiza-
tional structure of the AMA, both internally
and as a federation.” Information more specific
than this has not been revealed, but is prom-
ised us in June in Atlantic City.

Our State Organization has reaffirmed the
advisability of continuing the medical research
program at the McAlester Penitentiary, has
actively supported loans to deserving medical
students, has furthered continuing medical
education and has encouraged medical service
in rural areas.

I have great admiration for the hard work,
loyalty, integrity and dependability of our
Committee Chairmen and their constituents.
We have a state membership to be proud of for
its ethics and its devotion to the service of the
public and this has made me very proud indeed
to be its spokesman for the past year.

Doctor Buck Wagnon, a prime organizer if
ever there was one, together with his hard
working and efficient committee have de-

veloped this meeting which portends to be the
best this State has ever known.

I would indeed be remiss if I did not give full
recognition and thanks to our three fine Ex-
ecutive Directors in the Association’s offices.
No President could function properly without
them. They are knowledgeable, efficient,
pleasant and productive. I doubt that any med-
ical organization has three who are finer.

There is, sadly, another great crisis facing
our Profession across this great land and I refer
to professional liability. We in Oklahoma are
enjoying at the present time a favorable situa-
tion, as compared with most other states, but
we in the Midwest cannot rely on the hope that
this will continue. We must prepare for the
possibility that devastating effects may reach
us as well. Recently, our national organization
has recognized that this crisis does exist and
has agreed to help, although stating it is pri-
marily a state problem. Our efforts to decrease
our jeopardy must be carried out with great
circumspection, but with equal determination.

Finally, I say once again, to you the leaders
of this great State Medical Association, that I
am deeply indebted to you for your confidence
and your great assistance. I could not have
worked for or with finer gentlemen in meeting
the challenge that this office of President pre-
sents. I salute you!

Jack L. Richardson, MD
President

Report of the
PRESIDENT-ELECT
(APPROVED)

Mr. Speaker, Doctor Richardson, Members of
the House:

During the past year, the work of our Presi-
dent, Doctor Jack Richardson, has been very
outstanding. He has worked with untiring
energy and the Society owes him a debt of
gratitude.

The Committees have functioned very com-
mendably during the past year. I want to
thank all of you who participated in the com-
mittee work, for this is the basis and back-
ground of our State Medical Association. The
work of two of our committees I feel has been
tremendously outstanding.

The Legislative Committee has done a
yeoman’s job during the past year, under the
direction of Doctor Barton Carl and under the
Staff Leadership of Mr. David Bickham. These

Journal / July 1975 / Volume 68

253

news

men, along with the other members of the
Committee, have done a tremendous job.

The Medical School Liaison Committee,
headed by Doctor C. S. Lewis, Jr., of Tulsa has
done an outstanding job during the past year.

Resolutions: There are a number of res-
olutions being proposed to which I would like
to speak.

Resolution No. 12 concerning AMA publica-
tions. I would recommend that this House ap-
prove that resolution on to AMA in Atlantic
City.

Resolution No. 1 concerning insurance claim
forms. I would recommend that this house ap-
prove that resolution.

Resolutions Nos. 2, 3, and 6 proposing volun-
tary AMA membership, instead of mandatory
membership. I would recommend that these
resolutions be put together into one substitute
resolution and that this house approve such
resolution, making the effective date of this
change on January 1, 1976. I would however,
encourage that all members of the Oklahoma
State Medical Association remain members of
the American Medical Association. There are
many reasons why we should remain members
of the AMA. First and foremost is because of
the instability of Medical Liability Insurance
today. It may come to a point where we have to
be members of the AMA in order to get Medical
Liability Insurance. Let’s don’t be caught
without it.

Resolutions Nos. 10 and 13. Non-
participation in U.R.

Resolution No. 14. Restrict the sale of
syringes.

The Oklahoma Medical Summit — As you
know, this is the second undertaking of the
Oklahoma Medical Summit. It appears at this
time that the upcoming Summit meeting will
even be a greater success than the Oklahoma
Medical Suihmit meeting of 1974. All of you
know that meetings, the caliber of this one
coming up, don’t just happen. This meeting
has been put together under the direction of
Doctor Buck Wagnon. Buck has done a tre-
mendous job. Working with Doctor Wagnon
have been three representatives from each of
the participating organizations, three from the
Oklahoma State Medical Association, three
from the Oklahoma Academy of Family Physi-
cians, and three from the Oklahoma City Clin-
ical Society. This entire committee has been a

254

very dedicated group, and the results will show
it. All three of the staff men of the Oklahoma
State Medical Association have worked hard
on their particular areas of the Oklahoma
Medical Summit, Mr. Blair, Mr. Bickham and
Mr. Kelsay. Harl Stokes, representing the
Oklahoma City Clinical Society, and the
Academy of Family Physicians has also done a
tremendous job, and we thank all of them for
their participation in this very worthwhile pro-
ject. Dee Hampton, the Executive Secretary of
the Oklahoma County Medical Society, has
also done a great job.

Mr. Speaker, I have two specific recom-
mendations in my address here today. I would
like for this address to be assigned to one of the
reference committees for approval or disap-
proval. Now please do not misunderstand me.
Just because I am the incoming president, I do
not expect this House of Delegates to act has-
tily on any recommendations that I come up
with. I have, however put in a considerable
amount of thought, and had much consultation
from other members of the Society, before mak-
ing any recommendations. I would like to
make one specific recommendation regarding
the Oklahoma Medical Summit.

Recommendation No. 1: I would like to rec-
ommend that our House of Delegates approve
upcoming meetings of the Oklahoma Medical
Summit in Oklahoma City for at least the next
three years. Many times, on the short notice we
have had it is somewhat difficult to obtain
some of the speakers and some of the commit-
ments that we could have otherwise had, had
we had a longer notice.

Recommendation No. 2: I recommend that
your new president be allowed to appoint an
Ad Hoc Committee to study the Committee
structure of our Association, and that the Ad
Hoc Committee be chaired by our new
President-Elect whoever he may be. Councils
and Committees should be studied and defined.

PSRO AND UR: Professional Services Re-
view Organizations and Utilization Review.
These two monsters continue to haunt us and
the problems change in these areas from day to
day, but whatever the change, let it be the pol-
icy of our State Medical Association to fight all
government, and other third party interference
with every method at our disposal. The Federal
Government interference continues to pop up
at every turn. We of the Medical Profession
must continue to support whatever policy can
deliver the best medical care possible to our
patients of Oklahoma.

Oklahoma State Medical Association

I want to acknowledge and thank the Aux-
iliary to the Oklahoma State Medical Associa-
tion. Their diligence and untiring work goes
on, and we do appreciate it.

I want to publicly thank the new Committee
Chairmen who have already accepted posi-
tions. It is through the Committees that we can
make our State Association a successful medi-
cal organization.

I want to ask the new officers who will be
newly elected this Friday and the hold-over of-
ficers for their support. They will be called on
many times for consultation and other help. I
will depend upon you.

During the past year I have been in the posi-
tion to observe the efficient work of our small
Executive Staff and their secretaries. Gentle-
men, we have about the most efficient Execu-
tive Staff in our headquarters office of any
state in the country. Our secretarial help is
excellent, but gentlemen, we are sorely under-
staffed, so it is up to you and me to make an
even greater contribution in the coming year,
and the coming years. It may be necessary to
hire some more people in the coming years. I
want to pledge the Oklahoma State Medical
Association’s continued support of the Okla-
homa Health Sciences Center, and their ad-
ministration. I want to extend a special wel-
come to Doctor William Thurman, the new
Provost of our Oklahoma Health Sciences
Center. Doctor Thurman, we pledge our sup-
port in every way, to you, and to our Health
Sciences Center. I want to acknowledge the
fine work of our Dean, Doctor Tom Lynn and
his staff, and pledge our continued support of
the Oklahoma University Medical School. Mr.
Speaker I want to acknowledge the fine work of
our Oklahoma State Health Department. Doc-
tor LeRoy Carpenter and his staff have turned
our State Health Department into a responsive
and responsible organization within the Medi-
cal Profession. We are proud of it. We are
happy to work with you, and we pledge our
support.

This year I am having a Committee on
Sports Medicine, a new committee — are there
any volunteers?

I would strongly recommend that we con-
tinue cooperation among all physicians
throughout our State, even though we have
some differences of opinion, our overall goals
are the same, we must continue to fight for a
common goal, that will continue to give our
patients the best medical care in the world. Let
the town and gown join hands. Let all

specialists and generalists unite and work to-
gether to make Oklahoma a better place in
which to live and an even better place in which
to practice medicine.

Mr. Speaker, in this address I have two specif-
ic recommendations. I request that this portion
of my report be referred to the appropriate ref-
erence committee for recommendation back to
this House of Delegates. I thank you for the
opportunity to appear before this House of Del-
egates today. Arnold G. Nelson, MD

Report of the
BOARD OF TRUSTEES
(APPROVED)

This report summarizes principal actions
taken by the Board of Trustees since the last
annual meeting. Actions taken by the Board at
its April 23rd meeting will be contained in a
Supplemental Report.

Actions reported from the July 14th,
November 17th and March 9th Board meetings
are as follows:

1. The Board of Trustees approved a major
campaign to bolster the University of Okla-
homa Health Sciences Center by preparing in-
formative printed materials to distribute on a
statewide basis, by developing a sound-slide
presentation about the OUHSC concerning its
achievements, its problems and necessary so-
lutions, and by conducting regional meetings
throughout the state on an urgent basis to pre-
sent a constructive program to physicians,
legislators and civic and business leaders. Up
to $20,000 was authorized by the Board for this
major and critical activity, and a voluntary
fund raising campaign was authorized to be
carried out among the membership to help de-
fray the total costs. Total costs of this very ef-
fective campaign carried out by the Medical
School Liaison Committee were $10,550 of
which $3,300 was taken from association re-
serves and $7,250 was generously donated by
OSMA members.

2. The Board of Trustees, acting on the au-
thority extended to it by the House of Dele-
gates, and confronted by a 202-24 vote of the
AMA House of Delegates in June which de-
feated any AMA effort to repeal the PSRO law,
voted on July 14th to authorize the Oklahoma
Foundation for Peer Review to apply for a fed-
eral planning contract to further develop an
operational concept for PSRO in Oklahoma. At
the time of this action by the Board, it was

Journal / July 1975 / Volume 68

255

news

expected that the federal Office of Professional
Standards Review would solicit contract pro-
posals in September. However, Congress was
slow to act on a PSRO budget request of $58
million for the fiscal year, and the final action
taken by House-Senate conferees was to ap-
propriate only $37 million for this activity. The
$21 million budget cut resulted in further de-
lays in new PSRO activity, and at this writing
there have still been no federal solicitations for
new PSRO contracts. However, at its
November 17th meeting, in anticipation that
contract proposals would soon be solicited, the
Board authorized the Foundation to develop a
planning contract proposal with the proviso
that it be resubmitted to the Board of Trustees
for final approval and, further, that it not be
submitted to Washington in advance of a defi-
nite contract solicitation. At its March 9th
meeting, the Board received and approved a
proposal prepared by the Oklahoma Founda-
tion for Peer Review for a $117,000 six-month
planning contract. To date, the federal Office of
Professional Standards Review has yet to open
contract bids and the proposal has not been
submitted to Washington.

3. On November 29th, the Secretary of HEW
issued new hospital utilization review regula-
tions affecting Medicare and Medicaid pa-
tients. Initially, efforts were made by the
Oklahoma Foundation for Peer Review to use
the PSRO knowledge it had gained to assist
Oklahoma hospitals in meeting the regula-
tions, especially since the Secretary’s regu-
lations left every hospital to its own devices to
determine medical criteria and operational
procedures. Meanwhile, it became evident that
some 50 smaller hospitals in Oklahoma could
not possibly comply with the regulations, and
the Board instructed the Executive Director to
issue a press release critical of the regulations
and supportive of the efforts of small hospitals
to resist this imposition. Subsequently, the
OSMA Executive Committee, acting within its
delegated authority, issued a statement to all
county medical societies and hospital chiefs of
staff urging them to delay any affirmative ac-
tion on the regulations pending the outcome of
a lawsuit filed by the AMA against the Secret-
ary of HEW for the purpose of seeking an in-
junction against implementation of the regu-
lations. This matter has continued to generate
controversy within the state and will be a sub-

256

ject for further consideration at this annual
meeting.

4. The Board took swift action in responding
to Public Law 93-641, the National Health
Planning and Development Act of 1974, a pro-
gram which could exact sweeping changes in
health care delivery and exact new and un-
precedented pressures on physicians, hospitals
and nursing homes. At its March 9th meeting
the Board was advised that precipitous federal
deadlines had been imposed regarding the di-
vision of Oklahoma into health planning areas
(called "Health Service Areas” in the law). The
Governor is required to submit such divisions
to the Secretary of HEW by May 3rd, and to
meet this deadline he scheduled 13 public
hearings throughout the state on March 20th
and sought recommendations from all in-
terested groups by April 3rd. A special OSMA
Ad Hoc Committee was appointed and in-
structed by the Board of Trustees to develop a
plan incorporating the concept of multiple, au-
tonomous HSA’s. The committee, with the help
of additional members of the Board of Trustees,
had representatives at the regional hearings
who testified as instructed, and an OSMA plan
to divide the state was developed and submit-
ted to the Governor by the April 3rd deadline
after having been approved by the Board by
mail ballot.

5. The Board took action on a proposed AMA
dues increase (to raise 1975 AMA dues from
$110 to $200). Acting on the results of a poll of
25% of the OSMA membership conducted by
President Richardson, which revealed over-
whelming opposition to the increase, the Board
left the OSMA Delegates to the AMA meeting
in Portland "informed” but uninstructed as to
their voting on this issue (OSMA Delegates
voted against the dues increase, which failed
and against the $60 assessment, which passed).

6. The Board adopted a position paper on
"Unionism in Medicine” which, generally
speaking, took the position that, except for em-
ployed physicians (ie. house staff), there ap-
pears to be little that a union can do for self-
employed physicians in the area of bargaining
that a professional association cannot do as
well. The Board of Trustees will continue to
assess the union movement in medicine and
adjust its policy as indicated.

7. The Board approved a resolution to be
submitted to the AMA House of Delegates at
its Clinical Convention in Portland which had
the effects of (1) providing for more local input

Oklahoma State Medical Association

into the formulation of AMA positions on na-
tional legislative issues, and (2) providing for
decentralization of the AMA lobbying effort for
the purpose of bringing the full strength of
American Medicine to bear on high priority
bills. This resolution and several like it from
other states were shelved by the AMA House of
Delegates.

8. Certificates of Accomplishment were ap-
proved by the Board on behalf of Robert M.
Bird, MD, former Dean of the University of
Oklahoma College of Medicine, and Howard B.
Keith, MD, former Chairman of the OSMA
Peer Review Committee. These awards are
herewith recommended for final adoption by
the House of Delegates.

9. Harry Wilkins, MD, Oklahoma City, was
selected by the Board to receive the 1975 A. H.
Robins’ Physicians Award for Community Ser-
vice.

10. Trustees endorsed in principle House Bill
1552 to establish a commission and to provide
funding for internship and residency training
programs in Oklahoma.

IT. Because of a nationwide decline in the
professional liability insurance market, and
other adverse factors which have created crises
in other states, the Board of Trustees, on rec-
ommendation of President Richardson, voted
to create an Oklahoma Professional Liability
Study Commission.

12. The OU College of Medicine faculty has
created an "Extramural Relationship Commit-
tee” for the overall purpose of strengthening
liaison with the practicing medical community
and the public. They will host a reception for
OSMA Officers and Trustees at the Summit
meeting and have requested that the Provost of
the OUHSC and the Dean of the College of
Medicine be appointed routinely on the OSMA
Medical School Liaison Committee, to which
the OSMA Board has agreed. Beginning with
the 1976 annual AMA convention, the faculty
committee will host a reception for OU alumni
and OSMA officials attending the meeting to
acquaint them with AMA business matters af-
fecting medical education.

13. Because of resolutions now pending be-
fore the House of Delegates, the Board voted to
retain AMA dues collections in Oklahoma
until such time as the House decides whether
or not to amend the bylaws to make payment of
AMA dues voluntary rather than mandatory.

14. The Board appointed the following indi-
viduals to serve as the OSMA representatives
on the Oklahoma Council for Health Careers:

Journal / July 1975 / Volume 68

Mrs. William Renfrow, President-Elect of the
Woman’s Auxiliary; Marcella Steele, MD,
Tulsa; David Bickham, OSMA Associate Ex-
ecutive Director.

15. The Board voted to co-sponsor a Leader-
ship Training Program for officers and key
committee personnel in cooperation with the
Oklahoma Academy of Family Physicians, the
Oklahoma County Medical Society and the
Tulsa County Medical Society.

16. A 1975-76 Board of Directors was ap-
pointed for the Oklahoma Medical Political Ac-
tion Committee.

17. Life Membership Applications were re-
ceived from county medical societies and were
approved by the Board on behalf of the follow-
ing physicians: B. B. Coker, MD, Durant; C. F.
Paramore, MD, Shawnee; L. J. Starry, MD,
Oklahoma City; Charles A. Royer, MD,
Sarasota, Florida; John R. Little, MD, Ok-
lahoma City; William Mussil, MD, Oklahoma
City; George H. Garrison, MD, Oklahoma City;
Floyd T. Bartheld, MD, McAlester; L. Chester
McHenry, MD, Oklahoma City; Howard C.
Martin, MD, Oklahoma City; Donald L.
Mishler, MD, Tulsa; J. D. Shipp, MD, Tulsa;
Marcella R. Steele, MD, Tulsa; Thomas L. Fos-
ter, MD, Ponca City.

18. Doctor Robert Bird was elected as a Cor-
responding Member of the OSMA.

19. Arthur I. Taubman, DDS, an oral
surgeon from Tulsa, was elected as a dues-
paying Affiliate Member of the OSMA.

20. Five OSMA members were excused from
paying 1975 dues as a result of financial hard-
ship.

21. The following physicians were awarded
50-Year Pins in the OSMA: L. Chester-
McHenry, MD, Oklahoma City; William N.
Mussil, MD, Oklahoma City; L. J. Starry, MD,
Oklahoma City; George H. Garrison, MD,
Oklahoma City; B. B. Coker, MD, Durant; and
Charles F. Paramore, MD, Shawnee.

22. The Board has recommended two
nominees for one appointment to the State
Board of Health: Francis W. Hollingsworth,
MD, El Reno; and, William McDoniel, MD,
Chickasha.

23. The Board of Trustees has authorized the
association president to select nominees to
submit to Governor Boren to fill vacancies on
the State Board of Medical Examiners which
were not attended to during the tenure of Gov-
ernor Hall.

24. For one appointment on the Board of

257

news

Mental Health, the OSMA Board has sent the
names of three nominees to the Governor:
Charles Smith, MD, Oklahoma City (incum-
bent); Max A. Glaze, MD, Muskogee; and
Wayne J. Boyd, MD, Bartlesville.

25. The Board of Trustees reports
ing breakdown of membership:

the follow-

Active Members

2,077

Active Dues-Exempt Members

Applications Pending

140

Life Members

177

Affiliate Members

Honorary Members

Junior Members

129

Total Membership

2,574

Supplemental Report
BOARD OF TRUSTEES
( APPROVED )

At the annual meeting of the Board of Trus-
tees held at 9:00 a.m. on April 23rd, the follow-
ing actions were taken:

1. John A. McIntyre, MD, Enid, was re-
elected to a one-year term as Chairman of the
Board of Trustees; James B. Eskridge, III, MD,
Oklahoma City, was elected Vice-Chairman of
the Board.

2. The Board reviewed business items to be
considered by the House of Delegates during
this annual session and took note of the
Secretary-Treasurer’s Report, a report which
reveals a bleak financial picture for the next
fiscal year.

In the report, the Secretary-Treasurer ex-
plains that OSMA dues have been constant
from 1973 through 1975, a period of three
years of consistent dues costs during a time of
significant inflation. In addition, the
Secretary-Treasurer noted that average dues
for state medical associations are $140 per
year, and itemized a number of comparable
state associations whose dues are considerably
higher than those currently charged by the
OSMA.

The Board of Trustees observed that the as-
sociation cannot operate another year at the
same level without experiencing a deficit,
especially if staff salaries are to be increased
and if staff capabilities are to be expanded to
meet expanding challenges. Moreover, the
value of the OSMA to its membership was dis-
cussed, and despite the Board’s knowledge that
many OSMA members may resist a dues in-

258

crease in any proportion, it was generally
agreed that our state association must not be !
permitted to deteriorate in any fashion.

With these realities in mind, the Board of
Trustees voted to request that the OSMA
House of Delegates adopt a dues increase for
1976 in an amount not less than $20 annually.
This increase will be consistent with dues
charged by other state associations and is felt
to be a reasonable reaction to the increasing
costs of operating our organization.

3. The Board accepted late resolutions Nos.
12, 13, 14, 15 and 16.

4. In response to requests from county medi-
cal societies, the Board adopted guidelines en-
titled "Telephone Directory Listings for Physi-
cians and Surgeons” as prepared by the Judi-
cial Council of the American Medical Associa-
tion. The Board recommends that these guide-
lines be furnished as such to all county medical
societies for their consideration as to local
adoption and use.

5. The Board of Trustees, responding to local
problems and to recent action taken by the
Judicial Council of the American Medical As-
sociation, adopted as policy the following
statement related to interest charges on delin-
quent accounts:

"The Judicial Council has considered the
matter of charging interest on unpaid bills of
physicians regularly over the past 8-10 years.

It adopted the following opinion in 1962:

"Since the practice of medicine is a profes-
sion and not a business, the practices adopted
by businesses are not necessarily suitable to
medicine. It is not in the best interest of the
public or the profession to charge interest on
an unpaid bill or note for professional services
not paid within a prescribed period of time nor
is it proper to charge a patient a flat collection
fee if it becomes necessary to refer the account
to an agency for collection.

"Despite requests to modify or rescind this
opinion, this Council has no information or
data which would indicate that charging in-
terest reduces the physician’s accounts receiv-
able or materially changes patient’s paying
habits. In view of this, the Council reaffirms its
1962 opinion regarding interest charges and
flat collection fees.

"It is not improper, however, for a physician
to add a service charge, equal to the actual
administrative cost of rebilling, on accounts
not paid within a reasonable time. Patient
must be notified in advance of the existence of
this practice.”

Oklahoma State Medical Association

6. The following physicians were re-
appointed by the Board of Trustees to full
three-year terms on the Board of Directors of
the Oklahoma Foundation for Peer Review:
Rollie E. Rhodes, Jr., MD, Tulsa; Arthur E.
Schmidt, MD, Oklahoma City; Maurice C.
Gephardt, MD, Muskogee; and William M.
Leebron, MD, Elk City.

7. In accordance with procedures for ap-
pointment of the Board of Directors of the
Oklahoma Medical Political Action Commit-
tee, the OSMA Board of Trustees has added
Jack L. Richardson, MD, Tulsa, and Mrs. Scott
Hendren, Oklahoma City, to the 1975-76
OMPAC Board of Directors.

8. Robert G. Tompkins, MD, Tulsa, has been
re-appointed to a three-year term on the
Editorial Board of The Journal of the Okla-
homa State Medical Association.

9. The following physicians have been
selected by the OSMA Board of Trustees as
nominees for one position on the State Health
Department’s ''Health Facilities Advisory
Council”: A. L. Johnson, MD, El Reno; Frank
W. Clark, MD, Ardmore; and Orange M. Wel-
born, MD, Ada.

10. The Board of Trustees reaffirmed its con-
tinuing sponsorship of the "Governor’s Com-
mittee on Employment of the Handicapped” at
the rate of $250 per year.

11. An Affiliate Membership in the OSMA
was approved for Donald C. White, MD, who
practices in both Kansas and in Bartlesville,
Oklahoma. At the Board’s option, in accor-
dance with OSMA bylaws, Doctor White will
be expected to pay full OSMA dues.

12. The Board of Trustees received a com-
plete report on the history and current status
of the association’s sponsored professional lia-
bility insurance program, as presented by Don
Blair, Executive Director and Rod Frates,
OSMA Insurance Counselor. In short, the as-
sociation program presently enjoys the lowest
premium rates in America and continues to
operate on an actuarially sound basis. How-
ever, because of external problems as evi-
denced by an almost total decline in the profes-
sional liability insurance nlarket, and other
factors such as unreasonable shock losses
being incurred in other states, cost adjust-
ments in the OSMA program may be experi-
enced in 1976. The Board of Trustees com-
mended Mr. Frates and the Council on Insur-
ance on the quality and thoroughness of their
report and expressed confidence in their ability
to maintain professional liability coverage for

Journal / July 1975 / Volume 68

Oklahoma physicians at the lowest possible
rates and under the best possible conditions.

13. Dues for 1975 by the United States
Chamber of Commerce were approved by the
Board of Trustees in the amount of $250.

14. The Board took note that proposals con-
tained in resolutions 5, 9, 10 and 13 could re-
sult in the association’s involvement in a pub-
lic relations program of significant magnitude.
While the Board does not wish to instruct the
House of Delegates or the reference committee
in any fashion regarding these resolutions, it
respectfully requests that any action taken by
either the reference committee or the House
with respect to utilization review regulations
and/or PSRO should be taken in a manner
which will accommodate the cost of carrying
out the adopted position in a successful way.

15. The Board of Trustees commends the
Editorial Board of The Journal of the Okla-
homa State Medical Association, and the Ex-
ecutive staff of the OSMA, for the quality of the
OSMA’s official publication, especially the
March issue on professional liability.

Report of the

SECRETARY-TREASURER
( APPROVED )

Financial Statement

The association's fiscal year ends on May
31st, at which time a complete audit of all ac-
counts will be prepared. In order to provide the
Delegates with an indication of the financial
status of the OSMA at this time, however, the
following estimates of income and expense, ex-
cluding the annual meeting, are presented:

INCOME

Dues

$230,000

Interest

8,500

AMA Commissions

2,200

Building Lease

4,200

Other Commissions

2,169

OUHSC Voluntary Contributions 7,250

Directory Income

3,500

Journal Advertising Sales

25,000

Estimated Total Income

$282,819

XPENSE

Fixed (General

Administration)

$170,000

Depreciation

5,000

Councils and Committees

13,000

259

news

Student Loan Fund

10,000

In-State-Travel

5,500

Out- State-Travel

19,500

Dues, Okla. Council for

Health Careers

2,000

Newsletter

2,000

Mortgage Payment

641

Journal

40,000

Directory

10,000

Commissions to County

Societies

2,010

Estimated Total Expense

$279,651

Estimated Surplus

$ 3,168

At the last annual meeting, prior to expendi-
tures made during the meeting, a budget for
the fiscal year just ending predicted an esti-
mated surplus of $16,400. However, as a result
of salary increases and overestimates of dues
income and Journal income, the expected sur-
plus was necessarily altered downward.
Nevertheless, if the expense estimates for the
current year prove to be correct, the predicted
expenditures of $279,651 compare favorably to
budgeted expenditures of $276,600.

It is clear, however, that a marginal income
to expense ratio has been reached in OSMA
operations, although the foregoing estimated
surplus could possibly be enhanced if "Okla-
homa Medical Summit” produces a surplus as
it did last year.

During the next fiscal year, June 1, 1975 to
May 31, 1976, it is expected that inflation will
continue to occur across-the-board. For exam-
ple, there will be a 10% increase in Journal
printing costs (which, hopefully, will be offset
for the most part by a corresponding increase
in Journal advertising rates if we are able to
maintain the same number of advertising
pages in an increasingly competitive field).

The OSMA dues were last raised in 1973
. . . from $100 to $120.

1975-76 Budget

With an estimated operating surplus for the
current year of only $3,168 (plus any windfall
which may result from the "Summit” meeting),
it appears unlikely that OSMA operations can
be sustained at the same level without suffer-
ing an operational loss. The average 1974 dues
for all state medical associations, according to
the best information available is $140. The

260

current dues for states of comparable size to
Oklahoma are as follows: Arizona — $130;
Colorado $150; Iowa — $200; Kansas — $125;
and Oregon — $155.

With the foregoing information about the
current fiscal year in mind, and without as-
suming a dues increase, it is difficult to present
a favorable budget for the coming year. How-
ever, the following is a "best estimate” of what
can be done:

INCOME

Dues

$233,000

Interest and Commissions

9,500

Building Lease

4,200

Journal Advertising, Sales

25,000

Directory Sales

3,000

Estimated Total Income

$274,700

XPENSE

Fixed (General

Administration)

$175,000

Depreciation

5,000

Councils and Committees

Public Policy

4,000

Insurance

1,000

Professional

Education

2,500

Socioeconomic

Activities

1,000

Public Health

1,000

Prof, and Inter-

vocational Relations

500

10,000

Journal

42,000

Newsletter

2,000

Student Loan Fund

10,000

In-State Travel

6,000

Out-State Travel

21,000

Oklahoma Council for Health

Careers

2,000

Commissions to County

Societies

1,500

Estimated Total Expense

$274,500

Estimated Surplus

$ 200

Again, annual meeting income and expense
are not included in the budget estimates, since
the format of each meeting and income-pro-
ducing potentials are not predictable. Neither
do the preceding budgetary estimates accom-
modate salary increases.

RECOMMENDA TION:

1. The financial circumstances of the Associ-
ation are self-evident, and the House of Dele-

Oklahoma State Medical Association

gates is invited to address itself to the situa-
tion.

Report of the

COUNCIL ON INSURANCE
(APPROVED)

Council Members

C. Alton Brown, MD, Oklahoma City, Chair-
man

Robert W. Kahn, MD, Oklahoma City
Howard A. Bennett, MD, Bartlesville
David D. Fried, MD, Altus
C. E. Woodard, MD, Tulsa
William G. Bernhardt, MD, Midwest City
William M. Leebron, MD, Elk City
Glen L. Berkenbile, MD, Muskogee
Robert A. Nelson, MD, Tulsa
Thomas C. Glasscock, MD, Ponca City
Roger Haglund, MD, Tulsa

SECTION I.

Group Term Life Insurance

The Group Term Life Insurance Program of
the OSMA is underwritten by the Massachu-
setts Mutual Life Insurance Company and has
been in effect since 1956. Since the inception of
the plan $958,027 has been paid out in claims
to members or to the heirs of members of the
OSMA. Two hundred sixty-one physicians’
wives are now protected under this competitive
program.

Loss experience during the last year has
been excellent. In fact, a dividend in the
amount of $2,297.95 was returned by the
Massachusetts Mutual to the OSMA. This
dividend will be carried forward as a credit
against the billing for each physician’s policy in
the coming year. If good experience continues,
we should enjoy another dividend this year.

In addition to life insurance, the policy also
includes features for dismemberment and loss
of sight benefits, waiver of premium if dis-
abled, and private flying coverage. In addition,
no individual physician may be cancelled un-
less the entire program is terminated.

SECTION II.

Disability Income Insurance

The OSMA disability income insurance pro-
gram is underwritten by the Washington Na-
tional Insurance Company. Doctors insured
under the program may select up to $2,500 a

month indemnity for periods of disability due
to illness or accident. There are optional wait-
ing periods before disability coverage begins,
and either a 5 year or "to age 65” benefit period
may be selected for disabilities due to illness
(life time benefits are payable in case of acci-
dent). Coverage is also available for private
pilots and there is an accident benefit of $5,000
for death or dismemberment.

Currently some 600 OSMA members are
protected under the program and last year
physicians received benefits from the plan in
the amount of $86,708.

Loss experience has been optimum over the
years of sponsoring the program, and it contin-
ues to be predictable.

SECTION III.

Overhead Expense Insurance

This program is underwritten by the Conti-
nental Casualty Insurance Company. The pro-
gram is doing very well from a loss standpoint.
However, even with the growth produced dur-
ing the last year’s active solicitation, the pro-
gram is still not as well participated in as
many other sponsored insurance programs of
the OSMA.

The program indemnifies a physician
against the cost of keeping his office open dur-
ing periods of disability. From $300 to $1,500 a
month coverage may be purchased for a dis-
ability period of 18 months. Benefits may be
used to pay the actual overhead costs, includ-
ing employees’ salaries, during periods of dis-
ability.

Premium costs are tax deductible.

According to insurance experts, physicians
more and more tend to buy additional disabil-
ity income rather than overhead expense cov-
erage. Overhead expense insurance is, how-
ever, still extremely valuable to the individual
physician in private practice. It provides cov-
erage above and beyond his disability coverage
at minimal price. Furthermore, there is a
growing trend toward limiting the amount of
disability income coverage an individual may
purchase. As this trend gains momentum,
overhead expense plans may well enjoy a surge
in popularity. For the rural physician in the
small town in individual practice, this plan is
an inexpensive way of picking up vital insur-
ance.

Journal / July 1975 / Volume 68

261

news

SECTION IV.

Major Medical Insurance

This is the newest insurance program being
promoted by the OSMA. It is underwritten by
the Washington National Insurance Company.
Apparently there are now 151 participants in
the program and although the loss experience
is too green to determine its rate liability at
this time, it does appear to be stable and pre-
dictable.

Since its inception on January 1, 1973, many
changes have been made in the program in an
effort to improve it and make it more competi-
tive. Coordination of benefits has been pro-
vided and most recently claim service has
moved from the home office of the company to
Oklahoma City. This move will facilitate rapid
and more accurate handling of claims.

A number of options are available in order
that a physician may design a program to meet
his own needs. The Council on Insurance
anticipates a major push during the coming
year to increase the enrollment in the pro-
gram.

SECTION V.

Excess Limits Liability Insurance Program

The OSMA’s Excess Limits Liability Insur-
ance Program is underwritten by the CNA In-
surance Company. Two years ago the INA
withdrew from the excess limits market
nationwide. At that time the OSMA Council on
Insurance established criteria for a replace-
ment company. Only one company, CNA, met
the criteria, and agreed to underwrite the pro-
gram in Oklahoma. While there is no accept-
able method of fairly comparing the price of
this type of insurance to other programs like it,
because of the coverage of professional lia-
bility, the rates in the program are considered
to be extremely competitive.

Most umbrella type coverages for individ-
uals extend to such well known liabilities as
automobiles, watercrafts, aircrafts, homeown-
ers, etc. However, in the case of a physician,
the umbrella coverage also extends to his pro-
fessional liability. The CNA umbrella program
drops down to the $100,000 limit of the basic
professional liability coverage offered in the
state of Oklahoma through INA, and goes up to

262

a $5 million limit based on the physician’s
needs.

At the present time, more than 1,600 physi-
cians in the state of Oklahoma have purchased
the umbrella insurance in addition to their
basic professional liability program. The loss
experience in the plan is good at this time, but
it must be kept in mind that as professional
liability losses exceed the $100,000 cushion,
the loss experience in excess limits could go up.
At the present time, losses in excess of that
amount are extremely infrequent. If the basic
professional liability program continues to be
stable, then the excess limits liability program
should remain sound.

SECTION VI.

Professional Liability Insurance

The OSMA’s Professional Liability Insur-
ance Program is underwritten by the Pacific
Employers Indemnity Company, a wholly
owned subsidiary of the Insurance Company of
North America. It has now been in force since
1967 and has provided a stable liability cover-
age for Oklahoma physicians.

Before going into a discussion about
Oklahoma’s Professional Liability Program, it
would be best to review the national situation.
Needless to say, the national situation is bleak.
There are entire states that are unable to pur-
chase professional liability coverage at any
price. Companies that have written this type of
program for years are getting out of the mar-
ket. It is projected that Class 5 physicians
(anesthesiologists, orthopedic surgeons, plastic
surgeons, etc.) may have to pay as high as
$40,000 for their coverage next year in the
state of New York. In other states premium
increases from 100 to 1,000 percent have been
announced.

The medical liability insurance situation
nationwide has reached crisis proportions.
There is now congressional interest in the
situation and several professional liability
proposals have already been introduced in the
U.S. Congress.

Senator Ted Kennedy of Massachusetts has
seen the crisis as another opportunity to con-
trol and direct a provision of medical care in
the United States. He introduced the National
Medical Malpractice Insurance and Arbitra-
tion Act of 1975 which would authorize the
Secretary of HEW to contract with "providers of

Oklahoma State Medical Association

health care services” who would choose to
participate in the program. The providers
would then pay an annual premium to a medi-
cal malpractice firm and would receive federal
coverage. In return for the federal coverage,
participants would be required to comply with
state licensure and relicensure requirements
which meet or exceed minimum standards to
be established by the Secretary of HEW. In ad-
dition, participating physicians would also
agree to accept review of their services by
PSRO’s, to accept as payment in full whatever
amount Medicare would establish as reason-
able, and would obtain concurring opinions
from a specialist prior to performing surgical
procedures. In addition, all malpractice claim-
ants and medical care providers would submit
medical malpractice disputes to non-binding
arbitration.

Senator Gaylord Nelson of Wisconsin has in-
troduced a bill which would authorize HEW to
set up a re-insurance program and to conduct
studies and experiments in professional liabili-
ty. coverage.

A major concern of your Council on Insur-
ance is that the "cure” to the malpractice situa-
tion in other states might be a "fatal disease”
for Oklahoma’s program. At the present time
legislation is pending in almost every state in
the union to help the malpractice situation.
Some of that legislation could affect the state of
Oklahoma. As an example, the state of New
Jersey considered writing a state law that
would require any insurance company doing
business in that state that was writing profes-
sional liability in any other state to also write
it in the state of New Jersey. If that proposal
had become law in the state of New Jersey, it’s
almost assured that INA would have cancelled
its professional liability coverage in the state
of Oklahoma, since this is the only state in
which it has that type of coverage.

When the New Jersey situation came to the
attention of the OSMA, Governor David Boren
interceded on our behalf by writing the gov-
ernor of the State of New Jersey and pointing
out how this legislation in his state would af-
fect Oklahomans.

Insurance companies writing professional
liability must be sensitive to the difficulties
that are being experienced nationally. They
are concerned that country-wide trends can af-
fect local programs. Even though Oklahoma
has a loss experience that is sound and stable,
the national loss trend must be a concern of the
INA officials.

Due to a combination of people and circum-
stances, the loss experience for Oklahoma is
very favorable. Because the plan has existed
for some years, it has been possible to compose
a loss development factor that reflects the
"tail” of professional liability insurance in the
state of Oklahoma. This has helped make the
premiums charged to individual physicians
more competitive.

Your Council on Insurance authorized the
Insurance Company of North America to re-
quest a premium increase for this year. Even
with this increase the INA rates in the state of
Oklahoma may well be the lowest in the na-
tion. Nearly 2,000 OSMA members purchased
this bargain-rate high quality plan. It is hoped
that the premium rate can stay stable in com-
ing years, but it must be recognized that mal-
practice claims and awards have taken a
marked upswing across the nation in just the
past year.

While Oklahoma appears to be a calm spot in
a sea of turmoil, it might be well to touch on a
few of the important factors that help preserve
the program. Prompt reporting of incidents by
individual physicians has helped preserve
necessary information and evidence against
future malpractice claims. INA’s top flight ad-
justors, the attorneys that the OSMA and INA
have jointly chosen to defend physicians, and
the spirit of cooperation between the associa-
tion and the company have been major factors
in preserving the program.

Your Council on Insurance, the Executive
Staff of the OSMA, the Insurance Counselor for
the OSMA and the INA will continue to work
together on this valuable and important pro-
gram. Because of the changing national situa-
tion, it will be necessary for us to constantly
monitor national trends and, perhaps, to at-
tempt to derive innovative new approaches to
this coverage.

In addition, the Council on Insurance has
pledged to undertake a vigorous claims pre-
vention program during the upcoming year.
We may be in contact with every county medi-
cal society asking for a time and place to con-
duct such a program at the local level.

Report of the

COUNCIL ON PUBLIC POLICY
(APPROVED)

Council Members

M. Joe Crosthwait, MD, Chairman, Midwest

City

Journal / July 1975 / Volume 68

263

news

Homer D. Hardy, MD, Tulsa

F. D. Kalbfleisch, MD, Lawton

Jake Jones, MD, Shawnee

Thomas C. Points, MD, Oklahoma City

Irvin B. Braverman, MD, Tulsa

Edward D. Greenberger, MD, McAlester

Gerald L. Beasley, Jr., MD, Duncan

George H. Garrison, MD, Oklahoma City

Jerold D. Kethley, MD, Shawnee

Tom S. Gafford, MD, Muskogee

Harlan Thomas, MD, Tulsa

James B. Eskridge, III, MD, Oklahoma City

H. E. Denyer, MD, Bartlesville

R. Barton Carl, MD, Oklahoma City

John X. Blender, MD, Cherokee

Duane Brothers, MD, Tulsa

David B. Lhevine, MD, Tulsa

Eugene S. Bell, MD, Tishomingo

State Legislative Committee

R. Barton Carl, MD, Chairman, Oklahoma
City

S. N. Stone, MD, Oklahoma City
Karl K. Boatman, MD, Oklahoma City
Robert S. Ellis, MD, Oklahoma City
Royce C. McDougal, MD, Holdenville
John R. Smith, MD, Oklahoma City
Joseph W. Stafford, MD, Enid
Marion C. Wagnon, MD, Del City
George H. Kamp, MD, Tulsa

William L. Hughes, MD, Oklahoma City
James B. Lockhart, MD, Tulsa
Perry Lambird, MD, Oklahoma City
William G. Bernhardt, MD, Afidwest City
Edgar W. Young, Jr., MD, El Reno
Worth M. Gross, MD, Tulsa
Alfred H. Bungardt, MD, Tulsa

Medical Heritage Committee
R. Palmer Howard, MD, Oklahoma City,
Chairman

George H. Garrison, MD, Oklahoma City
William R. Paschal, MD, Oklahoma City
Neil B. Kimerer, MD, Oklahoma City
Winifred A. Showman, MD, Tulsa
Clinton Gallaher, MD, Shawnee
E. C. Mohler, MD, Ponca City
B. E. Blevins, MD, Midwest City
Pat Fite, Sr., MD, Muskogee

SECTION I

COUNCIL ACTIVITIES
Your Council on Public Policy is responsible
264

for several of the Association’s most important
activities. Public Relations, Internal Com-
munications, Federal and State Legislation are
all within the purview of this Council.

The State Legislative Committee is most ac-
tive and many good doctors are sacrificing a
considerable amount of their time on your be-
half. The work load has never been greater, nor
the legislation more important; they need your
help and active support.

Last year, we developed an ambitious Public
Relations campaign. We have implemented
some of the recommendations you approved.
Others, because of other more pressing obliga-
tions, have been held in abeyance. They will be
put into effect as time and resources are avail-
able.

The rrOSMA Comment” and the rr< Journal of
OSMA” are our principal internal communica-
tions tools. The Journal, for similar reasons,
reported in the past, still is in financial diffi-
culty. Comment, the two-page newsletter, ap-
pears to have good readership and because it is
quick to produce, offers us the opportunity to
communicate with our members quickly. In-
formation on legislative affairs is disseminated
through a weekly Legislative Reporter. That
publication has a limited mailing list of 200 or
so physicians who are interested in State legis-
lation. Any member can be put on the mailing
list.

The Association’s actions on the Utilization
Review regulations are well known and cov-
ered in other reports before the delegates.
While a reprieve has been achieved, there is
evidence that there is more to come. Delegates’
action on this critical issue could considerably
increase the activities of this Council.

Due to domestic, economic and foreign policy
problems, the Congress seems reasonably quiet
about National Health Insurance. However,
this volatile subject could emerge at any min-
ute.

Jurisdictional battles and funding problems
apparently have stymied the implementation
of PSRO. The deadline for operational pro-
grams is still January, 1976, but planning
funds have yet to be released. The future of this
program is very confusing. OSMA members
will be kept well informed on this subject.

Finally, there is now a move in the Congress
to "assist” in the current malpractice insur-
ance crisis. Learned authorities have indicated
that the Federal government has a limited, if
any, role in the medical liability problem, but,
nonetheless, several bills have been filed —

Oklahoma State Medical Association

some with major ramifications. It is the cur-
rent opinion of the Council that professional
liability insurance is a state problem and
should be handled at the state level. More de-
tails on this matter are included in the Council
on Insurance report.

RECOMMENDA TION:

1. That the activities of the Council be con-
tinued.

SECTION II

STATE LEGISLATIVE COMMITTEE

Since the 1st Session of the 35th Oklahoma
Legislature is still in session, it is not possible
to give the House of Delegates a complete
Legislative report. Actions by the Delegates
last year aided considerably the efforts of this
Committee. The influence of OMPAC in State
races has improved our ability to represent the
Association at the State Capitol. However, the
interest of lawmakers in the business of
medicine is ever increasing. Each year we see
more and more medical bills introduced. Too,
we are faced with problems that require legis-
lative solutions. The net result is a work load of
significant proportion. The Committee cur-
rently has under scrutiny a total of 99 bills.
Some require little effort; others require con-
siderable time, staff and committee work. A
few require the cooperation of all Oklahoma
physicians. The alarming fact is that the "few"
are becoming larger in number, partially be-
cause we have initiated more legislation than
in past years.

Last year your Council on Public Policy, of
which this Committee is a constituent, re-
quested approval of five recommendations.
They were:

1. That OSMA continue its policy of assign-
ing one staff member the primary lobbying re-
sponsibility.

This policy has been maintained. However,
it has been necessary this session to hire addi-
tional help on special projects. This process has
worked extremely well, and we hope you will
approve of such expenditures when they are
necessary.

2. That additional financial support be
granted for defraying the expense of mass
mailings to the membership.

The Committee has notified the entire as-
sociation membership of pending legislation on
one occasion this year, but may need additional
assistance before the session ends.

3. That an automatic typewriter be leased or
purchased to improve communication.

Journal / July 1975 / Volume 68

This has been one of our most effective tools
during this session. It is possible to write over
one hundred personal letters in one working
day. We have communicated with the entire
Senate and all of their physician contacts in a
matter of hours. Response from Legislators and
doctors has been very good. The machine is a
Redactron Twin Tape Computer with an IBM
Selectric typewriter leased for approximately
$285 per month. We appreciate your approval
of this new equipment.

4. Installation, if feasible, of a Watts Line
(state) for improved communication.

Initial surveys did not justify the expense of
a Watts Line. However, we currently have
under review by telephone personnel, our en-
tire system and both local and long distance
calls. We expect a report in the near future
which may require reconsideration of the
Watts Line.

5. Full Support of OMPAC

For the past seven years, because of in-
creased physician support, OMPAC (Okla-
homa Medical Political Action Committee) has
increased its contributions to candidates for
state offices. Their success ratio has been high.
Many of the members now serving in the
Oklahoma Legislature are recipients of modest
OMPAC contributions. It is important that we
continue that trend. All OSMA members
should be members of OMPAC.

In addition to these requests we suggested
that liaison with our medical specialty organi-
zations be improved and expanded. We now
have Legislative consultants from seven spe-
cialty organizations.

The Ladies Auxiliary sponsored another
"Doctors’ Wives Day at the Legislature” pro-
gram. Well over one hundred women attended
the half-day program featuring Governor
Boren, Legislative leaders and Acting Dean,
Thomas Lynn, MD. Auxiliary members have
expressed a sincere interest in helping our
Committee with its legislative program but,
we are still unable to capitalize on this valu-
able resource. We hope to in the next legisla-
tive session.

Physicians serving as Doctor of the Day are
certain to recognize the new and improved
quarters. The Capitol First Aid Station has
been moved to the 3rd floor. We now have two
rooms and water, a considerable improvement
over previous years. This is still one of OSMA’s
most succesful public relation efforts and we
encourage every physician to serve at least
once. Necessary backup facilities are available

265

news

at the Family Medicine Clinic and University
Hospital.

Our Legislative Liaison Committee func-
tions as our "crisis to crisis” committee. Almost
200 physicians who have agreed to contact
their legislators at the committee’s request re-
ceive the almost weekly "Legislative Repor-
ter.” Staff workload has hampered the reg-
ularity of the Reporter. We are now getting re-
quests from Legislators for our weekly publica-
tion, an indication of their interest about our
opinion on Legislation. Any OSMA member
who wants to receive the report can do so by
sending his name to OSMA headquarters. Our
Committee appreciates the efforts of many
members who work on Legislative affairs.

There are many bills introduced in the
Oklahoma Legislature that can have serious
repercussions on the practice of medicine —
bills that affect the physician-patient rela-
tionship, bills that would permit acts that are
harmful to patients, bills that provoke profes-
sional liability actions and bills that affect our
medical school. But there are also bills that can
improve the quality of health care in Okla-
homa, bills that can improve the distribution of
physicians, that will help finance medical edu-
cation for needy medical students, that will
eliminate many communicable diseases in our
young people, provide insurance coverage for
the newborn, help our medical school and aid
our attorneys in defending malpractice suits. A
summary of the most important bills follows
Specific information or copies can be obtained
from OSMA headquarters.

Summary of Bills

HB 1085 - Creating a Separate Board of Re-
gents for OUHSC. This proposal would remove
the Health Sciences Center from OU Regents
jurisdiction and establish a new, nine member
board to govern the Center’s four colleges of
Medicine, Health, Dentistry and Nursing. This
measure received considerable opposition from
educators, politicians and the OU Medical
School Alumni. The bill is in the House Ap-
propriations and Budget Committee and will
probably remain there for the rest of this ses-
sion.

HB 1104 - Appropriation to the Rural Medi-
cal Education Loan and Scholarship Fund. In

266

keeping with his promise to the Joint Session
of the Oklahoma Legislature, the Governor has
recommended an increased appropriation for
the scholarship fund. If the bill is passed it will
be for a total of $200,000 rather than $100,000
appropriated in previous years.

HB 1159 - Requiring the Board of Pharmacy
to Prepare a List of Drugs. This bill would have
required that the Oklahoma Board of Phar-
macy prepare a list of the 100 most frequently
prescribed drugs together with the two most
common quantities in which they are filled and
then distribute the list to each pharmacy in the
State. The bill was defeated on the floor of the
House of Representatives.

HB 1160 - Permitting Pharmacists to Substi-
tute Drugs. This is probably the most controver-
sial bill OSMA was involved in during this
Legislative Session. Existing Oklahoma law
permits pharmacists to substitute for a pre-
scribed drug with the permission of either the
prescriber or the purchaser. This law has re-
ceived considerable publicity in the past two
years. It was the opinion of OSMA’s Legisla-
tive Committee that unilateral substitution
was not in the best interest of the patient and
that the majority of physicians would want to
know if their patient received a drug other
than the one prescribed. Representative
Hammons’ bill as introduced, was not com-
pletely acceptable to the Committee, but the
basic provisions of the bill did require that the
physician have some knowledge of the sub-
stitution. We agreed to support Representative
Hammons’ bill with the understanding that
amendments would be accepted requiring that
bioequivalency be considered as a primary
criteria for drug substitution. The bill was op-
posed vigorously by representatives of the drug
manufacturing industry and by the Phar-
maceutical Association. Representative Ham-
mons did not amend the bill as he had agreed
to and the bill was voted down in committee on
the first hearing by one vote. Later in the ses-
sion, Representative Hammons introduced a
Committee Substitute for HB 1160, which was
wholly unacceptable to OSMA’s Legislative
Committee. We vigorously opposed the bill on
the floor of the House of Representatives but it
was passed by a narrow margin. It is now in
the Senate Committee on Public and Mental
Health and will receive a public hearing on the
day of the Reference Committee Hearings of
OSMA. It is doubtful that the bill will be re-
ported from Committee this session.

Oklahoma State Medical Association

HB 1237 - A Revision of Oklahoma s
Workmen s Compensation Code. Each year the
Oklahoma Legislature considers amendments
to Oklahoma’s Workmen’s Compensation Code
with the express purpose to bring the Code
more in line with Federal requirements and to
change or alter the schedule of payments in
keeping with the current salary rates. This
year, a provision was put in the bill to restrict
medical payments to conform to the schedule of
benefits as outlined in the State’s Health and
Accident Insurance Plan. In other words, the
workmen’s compensation schedule would be
compared to an accident and health insurance
policy schedule that does not take into consid-
eration the nature of industrial injuries. At the
present time, the bill has passed the House of
Representatives and is in a Senate Committee.
We have secured the necessary commitments
to have the above mentioned provision of the
bill removed. However, at this date, the bill
has not been reported out of committee as
amended.

HB 1307 - Changing population Require-
ments For Rural Medical Education Loan and
Scholarship Funds. At the current time, the
State’s Rural Loan and Scholarship Fund has a
requirement that recipients of the State
monies are to practice in a community with the
population of less than 5,000 after they
graduate and finish their training. This law
would raise that population ceiling to 7,500.

HB 1352 - Prohibiting Out of State Students
to Enroll in the OU Medical School. This prop-
osal would simply prohibit any out-of-State
applicant to be enrolled in the OU College of
Medicine. Existing law prohibits the enroll-
ment of more than 20% of any class, however,
this percentage has not been reached in recent
years. There has been some disenchantment
with the admissions policies of the OU College
of Medicine, as is evident by other reports be-
fore the Delegates. However, it does not appear
that this bill will be passed in this session of
the Legislature.

HB 1381 - Permitting the Introduction of
Printed Matter as Evidence in Civil Actions.
The Legislative Committee has reviewed this
proposal for several years which would permit
any type of publication, learned treatise, etc, to
be used as evidence when trying a civil law-
suit. This would be particularly harmful to the
defense of professional liability cases and for
that reason, we have opposed the bill. It is dead
for this Session of the Legislature.

Journal / July 1975 / Volume 68

HB 1357 - Granting Minors the Right to
Consent for Health Services. This proposal is a
modification of a model act recommended by
the American Academy of Pediatrics. We have
found that there are many problems associated
with providing health services to minors. Be-
cause of their incapacity to consent for treat-
ment, there are legal problems which some-
times cause the physicians to be reluctant to
provide the care. This bill would make it per-
missible for the physician to provide the
treatment without notifying the parents if he
so chose but it leaves to his discretion the right
to contact parents or guardian. Copies of the
bill were mailed to all OSMA members.

HB 1540 - Creating Board of Optical Dispen-
sers and Providing for Licensure. Several times
in the past years, OSMA has supported the
concept of licensing or certifying dispensing
opticians. HB 1540 would create a Board and
put them under the authority of the State
Board of Medical Examiners. However, the bill
did not receive favorable consideration by the
Committee and it is being held over until next
session. A similar bill is being considered in
the Senate, SB 441.

HB 1542 - Providing a Method Whereby a
Loan From the Rural Medical Education Loan
and Scholarship Fund Can Be Repaid. This bill
would permit a recipient of a rural medical
education loan or scholarship, the right to
repay his obligation to the State by serving in
the Oklahoma State Penitentiary. The only
means by which a commitment could be fulfil-
led at the present time is by serving in a com-
munity of less than 5,000.

HB 1552-Providing for State Subsidy of In-
ternship and Residency Programs. This legisla-
tion has probably consumed more of the
Committee’s time than any other single bill. It
is the result of recommendations made by the
Medical Center Liaison Committee and would
establish a 15 man commission to analyze the
physician need in Oklahoma, the distribution
of physicians in Oklahoma, and the training
programs for interns and residents and the lo-
cation of those programs. It would authorize
the commission, seven members of whom will
be named by the Governor, (the other eight are
named in the bill by title), to pay up to 50% of
the cost of an intern or resident to an institu-
tion that has an accredited program. The bill is
very complex since it attempts to deal with the
mal-distribution problem, the training of
primary care physicians and the location of

267

news

training programs. Copies of the bill are avail-
able at the OSMA office.

SB 122 - Extending the Statute of Limita-
tions. The existing law permits the claimant
two years in which to file a lawsuit to recover
damages. This proposal would extend that
period of time to three years. OSMA is very
much opposed to lengthening the Statute of
Limitations because of the impact it could have
on our professional liability program.

SB 228 - Permitting Patients Access to Medi-
cal Records. This measure would have in its
original form, formalized existing common
law, inasmuch as it has been ruled by the
Court that a patient has a right to information
in his medical records. We were concerned
about this bill because of the potential prob-
lems it posed to physicians and it may be con-
strued by the physician and the patient that
the medical record itself, had to be turned over
to the patient. The bill was amended to that
effect on the Senate Floor and is now in a
House Committee. We are making every effort
to have the bill amended to read as it was orig-
inally introduced or have it killed.

SB 236 - Permitting Claimants Under
Workmen’s Compensation to Sue For Negli-
gence. Existing Court law protects a physician
who renders services to an injured workman
covered by Workmen’s Compensation. The
Court has held that the physician is an agent of
the employer and therefore the injured
worker’s claim is against the employer and not
against the physician. This bill would remove
that "Halo of Immunity” and could result in a
great number of lawsuits against physicians.
For that reason, we have vigorously opposed
the bill and apparently it will not be passed in
the Senate this session.

SB 243 - Providing For The Formation of
Health Maintenance Organizations. This is
permissive legislation that permits the forma-
tion or organization of a Health Maintenance
Organization. The regulatory authority is ves-
ted in the Health Planning Commission and
rules and regulations controlling HMO’s would
be written by the Commission.

SB 273 - Requiring Health Insurance Com-
panies to Extend Coverage For the Newborn
from the Time of Birth. OSMA’s Legislative
Committee was asked to introduce this bill by
the Oklahoma County Medical Society and
thus far the bill is progressing well through the

268

legislative process. Hopefully, it will be
enacted this session.

SB 274 - Requiring Basic Immunization for
Children in Child Day Care Centers. Existing
law requires that before any child can enter a
public school for the first time, that he have
basic immunization. This measure would sim-
ply lower that age to those children that are in
Stae licensed child day care centers.

SB 255 - Defining Death. The current law
defining death is antiquated and does not per-
mit the flexibility necessary for organ removal
and transplantation. For that reason, the
Legislative Committee has supported a bill
that changes the definition of "dead body” to
mean a human body in which there is irrever-
sible, total cessation of brain function; and if
based upon ordinary standards of medical prac-
tice, during reasonable attempts to either
maintain or restore spontaneous circulatory or
respiratory furictions, it appears that the body
cannot be resuscitated. The definition con-
cludes with "death is to be pronounced before
artificial means of supporting respiratory and
circulatory function are terminated and before
any vital organ is removed for purposes of
transplantation.” The Legislative Committee
worked with several consultants on the lan-
guage of this bill.

SB 278 - Requiring a Certificate of Need For
The Development of or Expansion of Institu-
tional Health Services. This legislation would
require that before a hospital or major health
service institution could expand or be con-
structed, the developers would have to secure
from the State Health Planning Commission, a
certificate of need. To conform to recently
passed federal law, Oklahoma must enact a
certificate of need bill prior to the end of 1976.

SB 312 - Regulation of Emergency Medical
Services. Governor Boren, in his address to the
Joint Session, emphasized the need to improve
Oklahoma’s Emergency Medical Services. SB
312 is an effort to provide some regulatory au-
thority over ambulance services and atten-
dants. The bill would give the State Board of
Health the authority to write rules and regula-
tions and minimum requirements for
emergency services. The Board would be ad-
vised by a special Emergency Medical Advis-
ory Committee appointed by the Governor.

SB 398 - Prohibiting the Practice of
Acupuncture By Other Than MDs and DOs.
The Attorney General has ruled that the
Oklahoma Statutes are void as far as the prac-
tice of acupuncture is concerned. This in es-

Oklahoma State Medical Association

sence means that anyone who wants to can
practice acupuncture and quite a few unqual-
ified practitioners are doing so. This bill is an
effort to restrict the practice of acupuncture to
MDs and DOs. It has been bottled up in the
Senate Committee and probably will not be
acted upon this session of the Legislature.

There have been a series of bills introduced
in the Senate at OSMA’s requests. The five
bills that deal with areas of professional liabil-
ity are intended to assist our attorneys in de-
fending medical malpractice cases and also to
discourage the filing of cases. The bills are SB
428, SB 429, SB 450, SB 451 and SB 452.

SB 428 provides that a counterclaim for
damages for abuse of process in filing may be
filed and litigated in the same action when the
action is for damages for personal injury or
death. In other words, a physician could
counterclaim a claimant for malicious or cap-
ricious suit and the counterclaim action would
be tried along with the malpractice action. SB
429 simply states that unless a physician puts
in writing his guaranty or warranty that no
action may be brought against him, for a
guaranty or warranty. SB 450 would reduce
the period of filing a lawsuit from the existing
two years to one year and it would also close
out any actions after four years of the alleged
incident. SB 451 would permit the introduction
of evidence about collateral sources available
to the claimant. In other words, if the claimant
had insurance that paid for some of the dam-
ages that he incurred, such as hospitalization,
etc., that fact could be made known to the jury.
The last bill, SB 452, just instructs the Court
under the conditions in which it can invoke the
doctrine of "Res Ipsa Loquitur.”

There are a considerable number of bills that
are not contained in this report that have seri-
ous ramifications. These bills are routinely re-
ported in the OSMA Legislative Reporter. If
any member of the House of Delegates or
member of OSMA would like to be put on the
Reporter mailing list, simply notify the OSMA
Office.

SECTION III.

MEDICAL HERITAGE COMMITTEE

While your committee has not been active
during the past year, it has pledged to begin its
1975-76 functions immediately. It is holding
its first meeting during this Oklahoma Medi-
cal Summit ’75.

Several years ago the OSMA Board of Trust-

ees authorized this committee to use a portion
of the basement of the OSMA building for stor-
age of records and artifacts of a historical na-
ture. In reliance upon this pledge, your com-
mittee has gathered a small quantity of such
items.

A few of these items are on display in the
lobby of the OSMA Headquarters Building in a
special display case purchased for that func-
tion. The remainder, however, are still in stor-
age.

A portion of those items currently in storage
will be used, when the opportunity arises to
assist the Oklahoma Cowboy Hall of Fame
with its Doctor’s Office display in the Old
Western Town located in the basement of the
hall.

Numerous other places were contacted re-
garding displays, including the Oklahoma Arts
and Sciences Foundation and the Oklahoma
Historical Society. However, most of these
organizations would prefer to have photo-
graphs, as opposed to artifacts. While your
committee has collected a great amount of ma-
terial, there are very few photographs includ-
ed. Anyone having knowledge of the location of
early photographs of doctor’s offices, hospitals,
medical personnel, pharmacies, or even veteri-
nary establishments, are encouraged to contact
the committee. The committee has the facili-
ties to have such photographs duplicated and it
will not be necessary for it to retain the origi-
nal photograph for any length of time.

One of the proposals that your committee in-
tends to implement during 1975-76 is that it
should serve as a repository for county medical
society records. During the past year, the
committee offered to receive and store the rec-
ords of the Pottawatomie County Medical Soci-
ety.

In order to carry out its intention, the com-
mittee will contact each county medical society
in the state and offer to receive and store all
past records of the societies. In the event the
societies prefer to retain their own records,
your committee will attempt to arrange for a
synopsis of such records to be compiled and
forwarded to the state headquarters. Such
synopsis to contain not only a general state-
ment of the information contained in the
county society records, but also information
regarding their location for possible use in the
future.

Last year, following a recommendation by
the House of Delegates, your committee en-
tered into liaison on medical heritage with the

Journal / July 1975 / Volume 68

269

news

Oklahoma Pharmaceutical Association, The
Oklahoma Dental Association, The Oklahoma
Nurses Association, The Oklahoma Hospital
Association, and The Oklahoma Veterinarians’
Association. All of the organizations indicated
their desire to enter into such liaison, and pro-
vided the OSMA Medical Heritage Committee
with the names of persons to contact.

During the next year, it is the desire of the
committee to actively pursue this liaison in an
attempt to establish a coordinated effort by all
of the organizations to preserve the records and
artifacts of Oklahoma’s Medical Heritage.

Report of the
FINANCIAL AID TO
EDUCATION COMMITTEE
( APPROVED )

Lucien Pascucci, MD, Chairman, Tulsa

Ed L. Calhoon, MD, Tulsa

Stanley R. McCampbell, MD, Oklahoma City

Jack L. Richardson, MD, Tulsa

Arnold G. Nelson, MD, Midwest City

The Association’s dues structure includes a
five dollar per member contribution to a Fund
that provides financial assistance to medical
students. Thus, each year this committee has
approximately $10,000 to be used according to
the By-Laws of the Loan and Scholarship Fund,
Inc. for loans, scholarships, grants, etc. Since
the Fund was established in the late 1950’s,
Oklahoma physicians have loaned or given
needy medical students almost $105,000. In
addition, a resolution passed by the House of
Delegates in 1972 solicits a contribution of $10
from each member of OSMA. The money goes
to a fund managed by the Dean of Student Af-
fairs. Since the resolution passed, Oklahoma
doctors have given in excess of $10,000. The
total, $115,600 is a solid refutation of any sug-
gestion that physicians are not interested in
medical students and in training more doctors.

Contrary to the belief of some, most medical
students enrolled in school today require some
type of financial assistance. Not only have tui-
tion and other direct schooling costs risen, but
students are as subject to the inflationary pres-
sures as others. The average cost of a year in
medical school has risen to $4,850 as compared
with $3,450 in 1969.

It is imperative that we continue to support

our Medical School. Some health manpower
bills introduced in Congress would require se-
vere commitments from Medical Schools before
capitation grants can be received and the con-
ditions on graduates are almost as onerous —
approaching involuntary servitude. If our state-
supported institutions are required to rely on
Federal dollars alone, we lose even more con-
trol of medical education.

Since 1970, the Board of Directors of the
Oklahoma Loan and Scholarship Fund, Inc.
(five immediate Past Presidents of OSMA) has
transferred its annual income to the Oklahoma
Foundation for Community Medical Care.
These transfers are in keeping with the House
of Delegates directives of that year to direct
our monies into programs that will increase
the number of doctors in rural Oklahoma. The
Foundation has filed a separate report with the
House.

The Committee feels the Fund is carrying
out the wishes of the House of Delegates and
we will continue to do so as long as we are
accomplishing our objectives or are given new
instructions by the House of Delegates.

Report of the

MEDICAL CENTER LIAISON COMMITTEE

Committee Members

C. S. Lewis, MD, Chairman, Tulsa
Oliver H. Patterson, MD, Sapulpa
Billy Dale Dotter, MD, Okeene
James W. Murphree, MD, Ponca City
G. Rainey Williams, MD, Oklahoma City
James V. Miller, MD, Ardmore
Frank H. Austin, MD, Lawton
Orange M. Welborn, MD, Ada
Kenneth W. Whittington, MD, Bethany
Howard P. Mauldin, MD, Oklahoma City
Robert S. Ellis, MD, Oklahoma City
Jack Parrish, MD, Seminole
M. Boyd Shook, MD, Oklahoma City
Earl M. Bricker, MD, Oklahoma City
Curtis B. Cunningham, MD, Clinton

The bleak conditions existent at the Okla-
homa Health Sciences Center eleven months
ago have faded with winter weather. A turn-
around has taken place. University and Center
officials can look back over the arduous pur-
suits of the past with substantial pride.
Likewise, Association members can lay partial
claim for the progress made. Just a few months
ago we had faculty resignations of major pro-

270

Oklahoma State Medical Association

portions — today our faculty is confident and
growing; a year ago, it appeared University
Hospital was destined for padlocking — today
it is solvent and expanding. The 34th Okla-
homa Legislature viewed OUHSC with disdain
— The 35th Oklahoma Legislature has been
very generous to the Center. These conditions
did not change without cause and your Medical
Center Liaison Committee played a major role
in the changing attitude toward the Center.

Faced with the crises mentioned above,
OSMA President, Jack Richardson, MD, in-
itiated a series of meetings with Center and
University officials. With the help of Commit-
tee members, the major problems of OUHSC
were isolated. Meeting after meeting resulted
in a refined program for trustee consideration
as follows:

Objective:

The objective of the project is to realize
higher levels of state funding of medical educa-
tion through the Legislature by creating a
broader understanding of and appreciation for
medical education excellence in the State of
Oklahoma.

Target Audiences .

To achieve its objective, OSMA will concen-
trate a mass communications program toward
three primary target audiences: members of
OSMA, members of and candidates for the
State Legislature, and the lay leadership of
key cities throughout the state. A secondary
audience will be the general public.

Timing:

The project must be conducted as soon as
possible after the state primary elections (Au-
gust 27) and completed before the next Legisla-
tive session begins.

Strategy:

The basic strategy is to present the story of
medical education in community meetings
with legislators and local leadership present
which will apply pressure of the constituents
upon the legislators to properly support medi-
cal education programs.

Communications Vehicles:

The basic communications vehicles to be
used are (1) a 10-12 minute slide presentation,

(2) a brochure which capsulizes the content of
the slide presentation, (3) newspaper publicity.
Implementation:

Target date for completion of the slide pre-
sentation and brochure is September 15.
OSMA will select and arrange for meeting lo-
cations, dates, staffing, etc.

Key Issues:

There are several key issues in this project
which will be highlighted in the materials.
These include:

(1) Does Oklahoma have enough physicians
and other health manpower? Do we have the
capacity to produce what we need?

(2) Do we have the ingredients for producing
excellence in medical personnel . . . faculty,
facilities, finances?

(3) Are we producing the right amount or the
proper kinds of physicians? Are they staying in
Oklahoma, and, if so, where?

(4) Are Oklahomans willing and able to pay
for better health care? If so, how?

(5) How does University Hospital relate to
quality health care for all Oklahomans?

(6) If you want more and better health care
for your family and all Oklahomans, what can
you do about it?

Approval by the Trustees resulted in the
presentation "Medical Education — Who
Cares? Special Report” (Copy in Delegates Fol-
der).

In August the President and the Committee
Chairman held a press conference and an-
nounced our intent to aid the Health Sciences
Center. The press release received broad
coverage plus favorable editorial comment as
did the conference with TV and Radio Stations.
In essence, the release covered these points:

1. Financial problems at OUHSC did hot
occur overnight;

2. That financial problems had been ignored
too long by the legislature and Center officials;

3. That mutual distrust contributed to the
problem;

4. That management of the Center must be
responsible and accountable;

5. That lack of foresight on the part of politi-
cal leadership caused the prolonged crisis;

6. That the lack of a plan to care for the med-
ically indigent was robbing the Center of edu-
cational funds; and

7. The OSMA leaders called upon the
citizenry and elected leaders to support the
Center.

The Committee adopted an ambitious
schedule for presenting its program. Fifteen
communities were selected and with the help of
local coordinators, volunteer faculty and com-
mittee members, the bulk of the sessions w*ere
conducted in a span of thirty days. As nearly as
possible speaking teams with representatives
of OSMA, the Committee, OUHSC and Uni-
versity Hospital were sent to each location.

Journal / July 1975 / Volume 68

271

news

The exact number of community leaders,
politicians, media representatives, Chamber of
Commerce officials, etc., who attended is dif-
ficult to estimate. However, we are sure that
more than a thousand have seen the presenta-
tion (the presentation has been given many
more times than the fifteen officially conducted
by OSMA).

The results have been encouraging. There is
a new confidence in the Center. Not all the
problems have been resolved, but there is a
cooperative attitude about solving them. Gov-
ernor Boren has been most cooperative and
supportive of the Center, honoring a commit-
ment he made during the campaign. The Legis-
lature has indicated they will assist by sup-
porting with State funds, internship and resi-
dency programs. Too, the appropriation for the
Rural Loan Program will be doubled if pending
legislation is passed.

Recently, the New Provost of OUHSC, Wil-
liam Thurman, MD, took charge of his position,
adding additional stability to the Center.

In summary it appears we have turned the
corner and the future is bright.

During the year, perhaps because of the
Center’s problems and our involvement, a new
relationship with the medical school faculty
developed. Faculty members who attended the
presentations received new insight about at-
titudes toward the Center. Likewise, non-
faculty physicians came to a better under-
standing of the faculty members’ problems. To
continue that dialogue and to preserve and ex-
pand the newfound relationship, the Faculty
Board created a Committee on Extra-Mural
Relations. The Committee is functioning well
and some of the results are evident at this
meeting — the OUHSC Faculty Board Recep-
tion. In addition, the Dean of Student Affairs
has been requested and has agreed to serve on
this Committee. In 1976, the Center will host a
function at the AMA Annual Meeting for
OSMA Officers, Delegates and OU Alumni
who may be attending the meeting. The Com-
mittee was also instrumental in arranging fa-
culty hosts and medical displays for a legisla-
tive reception held April 14.

Students, Interns and Residents have de-
monstrated interest in the Association pro-
gram and we have maintained liaison in vari-
ous ways. Medical students have developed a
program for Summit — a first time occurrence —
and at various times during the year have of-

272

fered to assist us in our educational campaign.
Residents’ wives are conducting OUHSC Tours
during the Summit meeting on Thursday and
Friday.

In previous years the Association managed
summer work projects for medical students.
This year, because of more pressing demands,
the Summer employment program is coordi-
nated through the Oklahoma Council for
Health Careers. For information contact Okla-
homa Council for Health Careers, 715 N.E.
14th, Oklahoma City, Oklahoma 73104.

A recent problem, upon which the Commit-
tee has not acted, is an attempt by Oklahoma
lawmakers to legislate the composition of the
OU College of Medicine’s Admissions Board.
Senate Joint Resolution 22, authored by A1
Terrill, Senator from Lawton and Representa-
tives Davis and Beznoska, also of Lawton,
would require that the Board be composed of
five members from the Administration and
Staff and one member to be selected by the
County Medical Society from each of the 24
Judicial Districts in Oklahoma. Within the
past few days we have been informed that the
authors of the Resolution would accept
amendments changing the language so that
two physicians would be selected by the state
medical societies from each of the six congres-
sional districts. The Committee is polling
members by mail for their opinion of the prop-
osal and hopefully we can report to the ref-
erence committee and the Delegates. OSMA’s
Legislative Committee has taken a position of
opposition to the bill as originally introduced.
They are attempting to meet with legislative
leaders.

To agree to a legislated admissions board
could set a bad precedence. Similar infringe-
ments could be enacted on all Oklahoma pro-
fessional schools, in fact, all state-supported
schools. Secondly, to agree to either of the
proposals is an admission that the existing
process is inequitable — a fact not supported
by recent acts of this Committee. While we
have had differences with the school in past
years, we have helped in developing the exist-
ing system that allows for recommendations to
the Board from the Oklahoma State Medical
Association and the Oklahoma Academy of
Family Physicians. We have insisted that 50%
of the Board be composed of practicing physi-
cians. The current Board has 20 practicing
physicians and four full-time faculty members.
There are also 9 medical students serving. Our
members have disagreed about the wisdom of

Oklahoma State Medical Association

students serving in the selection process and
questions have been raised about the number
of out-of-state students admitted.

Because of the controversy on this issue, the
Committee Chairman has agreed to co-author
a Resolution with the Chairman of the Legisla-
tive Committee requesting a study of the OU
College of Medicine’s admission policy and the
effect of that policy on the distribution of
physicians in Oklahoma. This Resolution
should not be construed to be critical of the
selection process, only to recognize that a study
could allay concerns and result in constructive
recommendations.

RECOMMENDA TION:

1. That activities of the Committee be con-
tinued.

Report of the
CONSTITUTION AND
BYLAWS COMMITTEE
(APPROVED)

Committee Members

George H. Garrison, MD, Oklahoma City,
Chairman

E. N. Lubin, MD, Tulsa
Arnold G. Nelson, MD, Midwest City
Paul H. Rempel, MD, Enid
Clinton Gallaher, MD, Shawnee
Leo E. Yates, MD, Oklahoma City
The bylaws of the Oklahoma State Medical
Association provide that the Constitution and
Bylaws Committee has the responsibility of
studying amendments to the bylaws and con-
stitution as proposed by members of the associ-
ation or by component societies. In addition,
your committee may originate amendments to
the constitution and bylaws, if it so desires. In
either case, the recommendations of the com-
mittee are to be forwarded to the House of
Delegates for final consideration and action.

Your committee is aware of only one move to
amend the bylaws of the association, and that
is the recommendation that American Medical
Association membership be removed as a re-
quirement for OSMA membership. In other
words, the recommendation has been made
that AMA membership be made voluntary in
the state of Oklahoma.

The question as to whether or not the AMA
membership requirement should be changed
has arisen numerous times in the past. On
each of those occasions your committee has de-

Journal / July 1975 / Volume 68

termined that it did not wish to take a stand on
the issue, but simply recommended the word-
ing to be followed by the House of Delegates if
it chose to remove this requirement. The com-
mittee will follow the same procedure this
year.

If the House of Delegates determines that it
wishes to drop the mandatory AMA require-
ment, the constitution and bylaws committee
recommends that it adopt the following word
changes in the OSMA bylaws: Amend Chapter
I, Section 1.00, of the bylaws by deleting the
entire last sentence of the section. All of the
wording, with the exception of the section
number and the title of Chapter II, Section 2.00
should be deleted, and the following wording
inserted in its place: "Members of this associa-
tion who elect to become members of the
American Medical Association, shall pay AMA
dues and assessments as levied for their ap-
propriate classification of membership. AMA
dues and assessments should be collected and
remitted by component societies in like man-
ner as state association dues and assessments.”

Chapter V, Section 7.036 should be amended
by inserting the words ". . . involving AMA
members . . .” to make the first sentence of
that section read, "Judicial decisions of the
Board of Trustees involving AMA members
may be appealed to the Judicial Council of the
American Medical Association in accordance
with that organization’s constitution and by-
laws.”

Further, in the event the House of Delegates
chooses to make AMA membership voluntary,
your committee recommends that all county
medical societies be instructed by the House of
Delegates to amend their bylaws accordingly.

Your committee must make three recom-
mendations for changes in the constitution and
bylaws. They all take the form of "house clean-
ing” amendments to correct oversights from
previous years.

Last year, the House of Delegates amended
the section of the bylaws designating the
association’s "general officers.” It neglected to
amend that portion of the constitution desig-
nating the general officers. Your committee
recommends that the constitution of the State
Medical Association be amended as follows:
Article VIII, Section 1, be reworded as follows,
"The general officers of the association shall be
the president, president-elect, immediate
past-president, vice-president, secretary-
treasurer, speaker of the House of Delegates,
vice-speaker of the House of Delegates, and

273

news

chairman of the Board of Trustees .” Section 2
should be reworded to read as follows: "General
officers shall be elected by the House of Dele-
gates at its annual meeting, with the exception
of the immediate past-president who shall re-
main as an officer in this capacity for a period
of one year following the completion of his term
as president and with the exception of the
Chairman of the Board of Trustees, who shall
he selected by the Board. The House of Dele-
gates may remove any general officer from of-
fice for cause.”

The other change in the bylaws involves the
new method being followed in conducting the
OSMA’s annual meetings. Now that the as-
sociation is holding meetings in conjunction
with the Oklahoma City Clinical Society and
the Oklahoma Academy of Family Physicians,
it can no longer meet the technical require-
ments of its own bylaws dealing with annual
meetings. Therefore, your committee recom-
mends that Chapter III, the Annual Meeting
Section of the OSMA bylaws, be repealed in its
entirety and replaced by the following lan-
guage:

" Section 1.00 TIME. The Annual Meeting of
the OSMA House of Delegates shall be held at
least 30 days prior to the Annual Meeting of
the American Medical Association. The precise
dates for the annual meeting shall be recom-
mended by the OSMA Board of Trustees.”

Chapter IV, Section 3.01 should be repealed
and replaced with the following language:
rr3.01 ANNUAL MEETING. The House of
Delegates shall conduct its annual meeting at
the time and place selected by the OSMA
Board of Trustees in compliance with Chapter
III, Section 1.00.”

Chapter X, Section 1.00 should be amended
to delete "annual meeting committee” and add,
in its place, "scientific assembly committee.”

Section 2.00 of that Chapter should be
amended to Lead as follows: "Scientific Assem-
bly Committee.” The Scientific Assembly Com-
mittee shall consist of at least six members,
appointed for staggered terms of three years
each by the president.

rr2.01 DUTIES. The Scientific Assembly
Committee, with the approval of the Board of
Trustees, shall work with all other interested
medical and allied health organizations to ar-
range for joint meetings of a scientific and
medical nature. It shall be responsible for as-
sisting in the planning, conduct and publicity

274

of such programs, and for the planning and
conduct of other related events and functions
not otherwise assigned to other association
committees and officers. The committee may
request the president to appoint special com-
mittees or advisory groups to assist in the
proper conduct of its program.”

The above outlined changes in the bylaws
will allow the OSMA to continue participating
in Oklahoma Medical Summit without being
in technical violation of its own bylaws.

Report of the

COUNCIL ON CONTINUING
MEDICAL EDUCATION
(APPROVED)

Council Members

Kenneth Whittington, MD, Bethany, Chair-
man

Royce B. Means, MD, Lawton

Ralph L. Buller, MD, Hydro

Clarence P. Taylor, MD, Ada

John W. Drake, MD, Oklahoma City

James C. Smith, MD, Tulsa

John A. Blaschke, MD, Oklahoma City

Wendell L. Smith, MD, Tulsa

Irwin H. Brown, MD, Oklahoma City

David E. Browning, Jr., MD, Tulsa

James F. Tagge, MD, Enid

James D. Loudon, MD, Shawnee

Y. E. Parkhurst, MD, Norman

Jack W. Parrish, MD, Seminole

William E. Dalton, MD, Oklahoma City

During this meeting last year, your council
polled Oklahoma physicians to determine the
type of medical education programs that would
be of most interest. We are now analyzing the
results of another survey asking the accepta-
bility of the Higher Regents Televised Instruc-
tion System as a media for continuing educa-
tion.

The survey run during Summit last year in-
dicates that physicians prefer scientific pro-
grams over socioeconomic subjects. However,
most stated that they would send office per-
sonnel to sessions on coding, billing and col-
lecting Medicare-Medicaid problems and Use
of Relative Value Studies. Your council chair-
man, and an OSMA staff member attended a
commercial course sponsored by the Oklahoma
Society of Internal Medicine which covered
many of the subjects mentioned above. Using a
similar program format and with the help of

Oklahoma State Medical Association

medical assistants, a course has been designed
for physician office personnel. The course has
been taught once and two others are scheduled
in May. The first course was oversubscribed. A
tuition fee is charged to defray all expenses
connected with the course.

Summit ’75’s scientific program, though not
directly related to the survey, is an attempt to
answer the need for special medical education.
Thirteen medical specialties are participating
in this program, the highest ever; in addition,
medical organizations such as the Medical Re-
search Foundation, Oklahoma Heart Associa-
tion and the Oklahoma Cancer Society are
conducting scientific sessions. A total of
seventy-two accredited hours will be offered
during the three-day affair.

Council representatives attended the Fourth
Biennial Conference on Continuing Medical
Education for State Medical Associations and
Specialty Societies sponsored by AMA. Con-
ferees spent two days discussing in detail the
need to qualify evidence of a physician’s con-
tinuing competence to practice his profession.
In other words, how can the physician dem-
onstrate his ability to practice good medicine,
self-assessment, re-certification, specialty test-
ing and re-licensure were explored. In general,
the Conference concluded that continuing med-
ical education is essential to good medical
practice; that medical societies should make ef-
forts to encourage participation in good scien-
tific programming; that primitive measures
were not incentives for participation; that re-
certification might be a good idea but there
were significant problems in implementation
and finally, while most conferees felt some con-
tinuing education requirements for member-
ship in State Societies, most rejected the idea of
a specific requirement for membership in
AMA.

The quality of continuing medical education
has been under scrutiny for a number of years.
AMA has developed a plan for accrediting
State Associations who in turn accredit pro-
grams conducted by state, local or specialty
units, ie, hospitals, specialty societies, clinical
societies, etc. Thirty-three states have been
approved as accrediting bodies. Your Council,
to date, has rejected this idea. Most of the for-
mal post-doctoral medical education in Okla-
homa can be accredited by the Department of
Continuing Medical Education for Physicians,
OUHSC. We have discussed, on several occa-
sions, the propriety of seeking accreditation
status with Irwin Brown, MD, Director of the

department. We feel it would be an unnec-
essary duplication of effort at this time. Our
Council works closely with Doctor Brown and
the Medical Center. Plans have been completed
for the co-sponsorship of some programs and
others are in the offing. Current programming
by the Department offers a variety of medical
education in different specialty interests and
locations. There are sincere efforts to broadcast
courses over the talk-back television network
but there are mechanical problems involved,
not the least of which is confidential, since the
network involves forty-five satellite stations in
institutions and industrial complexes.

The college of medicine has agreed to de-
velop a special assistant program for physi-
cians. Hopefully, a plan can be designed to pro-
vide the latest information on a particular sub-
ject to an individual physician upon telephone
request. Basically, a call to the Department of
Continuing Medical Education requesting in-
formation would be channeled to a particular
faculty member who would call the requesting
physician. The faculty physician would survey
the available information and direct the staff
of the department to send appropriate informa-
tion along with suggestions for reading. It is
possible that this type course work can be
accredited. However, mechanisms for assess-
ment and financing must be established.

The Council will continue its efforts to make
certain that Oklahoma physicians have the
opportunity to enroll in quality continuing
medical education programs at the local, re-
gional and state level. We will avail ourselves
of all resources, both private and govern-
mental to accomplish that goal. However, it
is the opinion of the Council that these pro-
grams should be self-supporting.
RECOMMENDA TIONS:

1. That the House of Delegates urge all
OSMA members to maintain their medical
competence through continuing medical study.

2. That all members be urged to work toward
AMA Physicians Recognition Award.

3. That the activities of the Council be con-
tinued.

Report of the

COUNCIL ON PROFESSIONAL AND
INTERVOCATIONAL RELATIONS
(APPROVED)

Council Members

Marion C. Wagnon, MD, Del City, Chairman
Norman A. Cotner, MD, Grove

Journal / July 1975 / Volume 68

275

news

Bryce C. Bliss, MD, Tulsa

Marvin K. Margo, MD, Oklahoma City

Kenneth G. Lowe, MD, Poteau

Don F. Rhinehart, MD, Oklahoma City

Orby L. Butcher, MD, Oklahoma City

Frank W. Clark, MD, Ardmore

Floyd F. Miller, MD, Tulsa

Fred W. Sellers, MD, Mangum

David P. Mitchell, MD, Madill

Medical-Legal Relations Committee
Medical Members

Marvin K. Margo, MD, Oklahoma City,
Chairman

Samuel O. Jack, MD, Lawton
Richard G. Dotter, MD, Oklahoma City
A. Munson Fuller, MD, Tulsa
Robert J. Rutledge, MD, Oklahoma City
Robert T. Rounsaville, MD, Tulsa
John T. Keown, Jr., MD, Tulsa
Tim K. Smalley, MD, Stillwater
Lowell N. Templer, MD, Altus
Joseph F. Messenbaugh, III, MD, Oklahoma
City

Attorney Members

George F. Short, II, Oklahoma City, Chairman

Holland Meacham, Elk City

James Foliart, Oklahoma City

Howard K. Berry, Jr., Oklahoma City

Joseph Glass, Tulsa

Ed Kelsay, Oklahoma City

Ben T. Lampkin, Oklahoma City

T. D. Nicklas, Lawton

William Dale Reneau, Oklahoma City

James E. Poe, Tulsa

Jefferson Greer, Tulsa

Dale F. McDaniel, Tulsa

Claim Mens Lietison Committee
Richard H. Burgtorf, MD, Shattuck, Chairman
Donald F. Rhinehart, MD, Oklahoma City
Orange M. Welborn, MD, Ada
James P. Bell, MD, Oklahoma City
David R. Brown, MD, Oklahoma City
Dan R. Storts, MD, Tulsa
William G. Mays, MD, Tulsa

Medical-Dental Liaison Committee
Jack L. Richardson, MD, Tulsa, Vice-Chairman
Howard P. Mauldin, MD, Oklahoma City
Ed L. Calhoon, MD, Beaver
Kent Braden, MD, Oklahoma City

276

Kenneth Whittington, MD, Bethany
Don Blair, Oklahoma City, ex-officio

SECTION I.

THE COUNCIL

By necessity, the Association must maintain
relationships with a variety of professional and
allied organizations. At times, these relations
become almost adversary, most of the time
they are amicable and result in a combining of
talent to accomplish a common objective. All of
the time they are maintained to facilitate open
communication and a forum for free discussion.

Fortunately, the vast majority of this
Council’s activities can be handled by able
committee chairmen and staff. We can enter
into common education programs with nurses
without formal Council meetings, we review
the problems in our Workmen’s Compensation
system without committee hearing. We work
with Pharmacists and Osteopaths in an ongo-
ing manner. Thus, the Council, while main-
taining its liaison commitments does not have
to meet except in those unusual situations
where extreme problems arise. While the past
year has been relatively quiet, there is every
reason to believe the Council will have to face
major issues in 1975-76. The reports of Com-
mittee Chairmen reflect major problems in the
area of cults and quackery and optometry. The
Council requests that special attention be
given to the report of the Claim Men’s Liaison
Committee efforts to improve the working re-
lationship between physicians and representa-
tives of third party payors deserves careful con-
sideration by the House of Delegates.

A review of the Council’s areas of concern
are as follows:

SECTION II

MEDICAL-LEGAL RELATIONS
COMMITTEE

Your committee has met several times dur-
ing the past administrative year. Its primary
function occurred July 18-21 when it conducted
the 1974 Medical-Legal Institute at Fountain-
head State Lodge on Lake Eufaula. 220 physi-
cians and attorneys attended the three-day
meeting.

The Medical-Legal Institute is held every
two years. The 1976 Institute has been sched-
uled for June 18-19 at Shangri-La Lodge on
Grand Lake.

Oklahoma State Medical Association

During the past year your committee was
asked to prepare a statement on preserving pa-
tient medical records. The committee recom-
mends that the following statement be adopted
as a part of this report:

"The Oklahoma State Medical Association
House of Delegates recommends that complete
patient medical records be retained in their
original form, for a period of six years, and in
either the original or a reproducable form (ie,
such as microfilm) for ten years after the most
recent patient care usage. After this period,
such records may be destroyed unless destruc-
tion is specifically prohibited by statute, ordi-
nance, regulation or law.

"The general recommendation may be fol-
lowed, with the following exceptions: physi-
cians are urged to retain complete medical re-
cords of minors for the period of minority, plus
two years, and they are urged to retain com-
plete medical records of patients under mental
disability in like manner as those of patients
under disability for minority, and retain com-
plete patient medical records for longer periods
of time when requested to do so by one of the
following: an attending or consultant physi-
cian of the patient, the patient or someone act-
ing legally in his behalf, or legal counsel for a
party having an interest affected by the pa-
tient medical records.

"Physicians are further urged to retain all
medical records which reflect an untoward in-
cident or an unexpected result from a surgical
or medical procedure.”

The adoption of the above patient record pre-
servation statement should allow many physi-
cians to relieve, to some extent their record
storage problem.

During the past year your committee has at-
tempted to adjudicate a number of grievances
involving both physicians and attorneys. In
each instance the committee relied upon the
code of interprofessional conduct adopted by
the OSMA House of Delegates and the Okla-
homa Bar Association’s House of Delegates
several years ago. The code has proven to be a
very workable document of great value to both
professions.

SECTION III

CLAIM MEN’S LIAISON COMMITTEE

During its 1973 meeting the OSMA House of
Delegates authorized the creation of the Claim
Men’s Liaison Committee in order to establish

a direct relationship with the Oklahoma Claim
Men Association. That instruction was reiter-
ated by the House of Delegates in 1974.

In the last year your committee has worked
with the Oklahoma Claim Men Association to
devise the following proposed "guidelines for
understanding between physicians and claim
representatives.”

Your committee urges the House of Dele-
gates to adopt these guidelines as written, but
at the same time to instruct your committee to
continue negotiations with the claim represen-
tative organization to create an even better
document.

The major difficulty faced by your committee
in working with the Oklahoma Claim Men As-
sociation is found in the fact that these men are
employees of large insurance companies. While
they are attempting to upgrade their own pro-
fession, they cannot speak for the companies
that employ them. If the company has a policy
that is contrary to any code or guideline, the
claim representative must abide by his com-
pany policy. Therefore, your committee has
found it necessary to write a guideline in very
broad and generalized terms. This is sometimes
repugnant to us, since there are specific things
we would like to include, but these would re-
quire formal concurrence by the individual in-
surance company.

Your committee does hasten to point out,
however, that the guideline as written is a
good working document that can be utilized by
our profession whenever dealing with an in-
surance claim representative.

The guideline is as follows:

Guidelines for Understanding Between Physi-
cians and Claim Representatives

The purpose of this guideline of under-
standing is to improve relations between doc-
tors of medicine and insurance claim represen-
tatives. Its provisions are intended as guides
for physicians and claim representatives in the
mutual desire to see that nothing in their rela-
tionship is detrimental to the interest of the
patient.

This guideline of understanding is not a pro-
nouncement of law, but constitutes suggested
rules of conduct for members of these profes-
sions, each subject to the principles of ethics
governing their respective members.

This guideline recognizes that doctors of
medicine and members of the claims profession
have areas of mutual responsibility and con-
cern. It is hoped by those that have partici-

Journal / July 1975 / Volume 68

277

news

pated in the development of this guideline that
by an improved relationship between the pro-
fessions of medicine and claim handling, the
public will be better served.

Basic Considerations

The physicians may be involved in the fol-
lowing doctor-patient relationship:

(1) Where the private patient is not covered
by any type of insurance protection.

(2) Where the patient is covered by govern-
mental third parties.

(3) Where the patient is covered by indi-
vidual or group coverage.

(4) Where the patient is involved in a liabil-
ity situation.

(5) Where the patient is covered by the
workmen’s compensation act.

This guideline will deal to whatever extent
is necessary with all of the above relationships
except the first (where there is no insurance
coverage involved.)

Governmental Third Party

Since the payment portion of the physician-
patient relationship in such cases is controlled
by federal regulation, and few insurance com-
panies are involved in these coverages, it is felt
that this guideline should leave any unusual
problems to resolution between the physician
and the fiscal intermediary involved.

Individual or Group Coverage

In this category fall those cases involving
Blue Cross and Blue Shield, as well as those
illnesses and accidents directly covered by pri-
vate insurance. The insured has the obligation
to report the covered loss in writing to the car-
rier within the time set out in the policy con-
tract. The insurance carrier then furnishes
claim forms with portions to be completed by
the attending physician and the insured pa-
tient. Although the paperwork in such claims
is substantial, misunderstandings are not
common in this area.

Liability Situations

All such cases involve the physician-patient
privilege relationship. The physician always
should require medical authorizations signed
by the patient before discussing any such case
with a claim representative or releasing any
information to a claim representative. The
claim representative should always furnish
signed authorization in such cases. He should
protect the physician’s bill where possible,
when furnished with assignment of interest.
He should expect to pay a reasonable fee for

278

any report requested. The fee should be dis-
cussed and agreement reached as to the
amount. Misunderstandings in this area often
can be avoided if arrangement can be made for
a short personal conference between the physi-
cian and claim representative, particularly
where they are not already personally ac-
quainted. The claim representative should not
appear at the physician’s office unannounced,
but after he makes the indicated contact
through the physician’s appointment desk, the
physician should make an effort to see him
promptly at the appointed time, since he, too,
has many contacts which must be made during
the course of a working day.

Workmen’s Compensation Cases

Treatment of industrial injuries and occupa-
tional diseases is a special, but not exclusive
province of the industrial physician. The rela-
tionship of physician to claim representative is
established by the specific provisions of the
workmen’s compensation act. The section of
the act dealing with medical treatment re-
quires that the employer promptly provide
such medical, surgical or other attendance or
treatment as may be necessary after the in-
jury. The attending physician shall supply the
injured employee and the employer with a full
report of injuries found at the time of examina-
tion and proposed treatment, this report to be
furnished within seven (7) days after the ex-
amination. Also, at the conclusion of the
treatment, the attending physician shall sup-
ply a full report of his treatment to the em-
ployer of the injured employee. This statutory
obligation removes the privilege from the
physician-patient relationship.

The workmen’s compensation insurance car-
rier should furnish to the attending physician
either the Statutory Form 4, "Attending
Physician Report” form, or the nationally ap-
proved "Surgeons’ Report” form for completion
in all cases. In cases not involving permanent
disability, the only other report generally re-
quired is the "final report and bill.” Particular
attention should be given to answering those
questions as to when the patient is able to re-
turn to work and whether permanent dis-
ability is involved.

It should be noted that permanent disability
evaluations are based on the statutory sched-
ule of compensation with reference to the per-
formance of ordinary manual labor and are not
necessarily based on impairment of function.

Mutual Understanding

Claim representatives are proud of the fact

Oklahoma State Medical Association

that professional standards are now set for
them and established by examinations ad-
ministered through the office of the State In-
surance Commissioner. This guideline of
understanding with the Oklahoma State Medi-
cal Association is further evidence of the in-
creasing professionalism of the claim industry.
The profession of medicine and the profession
of claim representatives reciprocally acknow-
ledge the foregoing obligations of conduct and
understanding.

Permanent liaison committees should be es-
tablished by both professional groups. Any
conduct or practice by a physician or claim rep-
resentative which might be of concern to the
other profession should be called to the atten-
tion of that liaison committee as soon as possi-
ble, so that it can determine whether discipli-
nary action might be indicated. Hopefully, any
misunderstanding which might occur could be
resolved by the joint liaison committee of the
two associations.

Your committee acknowledges that the
above guidelines are imperfect and require
more work. It pledges to work with a commit-
tee of the Claim Men’s Liaison Organization to
perfect the guidelines during the next year.
The fruits of its labor shall be brought back to
the House of Delegates in 1976.

SECTION IV

MEDICAL-DENTAL RELATIONS
COMMITTEE

In 1970 the officers of the Oklahoma State
Medical Association and the Oklahoma Dental
Association determined that it would be bene-
ficial to both organizations to have a joint
liaison committee. Five members from each
organization were selected to serve by virtue of
the positions they held in their respective or-
ganizations. It was felt that the Dental and
Medical Associations could have joint interests
in education programs, peer review, political
action, rural medicine, public relations and
problems associated with the delivery of health
care.

During the past four years the committee
has had sporadic activity. While a few prob-
lems of mutual concern did surface, most of
them were handled at the staff level with very
little difficulty. Although the committee did
not meet during the last year, it does provide
an appropriate mechanism to be utilized in the
event a joint problem does arise.

SECTION V

CULTS AND QUACKERY

Last year the Council requested that a Cults
and Quackery conference be conducted in
Oklahoma City to draw attention to the char-
latanism of unethical practitioners. We have
seen considerable abuse in the past in areas of
weight reduction, and more recently abuses in
the so-called "practice” of acupuncture. Repre-
sentatives of the Association met with mem-
bers and staff of AMA Coun il on Cults and
Quackery and tentative arrangements were
made for a conference in the fall of ’74 or
winter of ’75. The Cult and Quackery Council
(AMA) planned to hold a meeting in Oklahoma
City. We planned to capitalize on the Council
talent thereby reducing expense to OSMA for
out-of-town speakers. Due to severe cut-backs
in AMA’s budget, the meeting could not be
finalized and because no definitive program
had been designed with clear cut objectives,
the conference was abandoned.

OSMA’s Legislative Committee has secured
authorship of a bill that would restrict the use
of acupuncture to MD’s and DO’s under rules
and regulations promulgated by the Commis-
sioner of Health. They also plan to have intro-
duced legislation that would require all prac-
titioners of the Healing Arts to be graduates of
schools recognized by a national accrediting of-
fice. Perhaps a conference could be planned,
designed to garner public and legislative sup-
port for the passage of these issues. There is no
doubt that the curtailment of charlatan prac-
tices is dependent upon public sentiment. We
still feel that quality health education is the
answer to much of this exploitation. Physi-
cians, cast in the role as the "favored” can
never eradicate cults by themselves.

SECTION VI
NURSES

The Association maintains a continuing
liaison with the Oklahoma Nurses Association.
They participate in our "Doctor of the Day”
program by furnishing a volunteer nurse each
day during the legislative session. We have
co-sponsored special continuing education pro-
grams for nurses, and physicians’ representa-
tives of the Association’s work with a local com-
mittee on the National Joint Practice Commis-
sion. The second National Conference on Joint
Practice is scheduled late this year in Chicago.

Journal / July 1975 / Volume 68

279

news

NJPC is an interprofessional organization to
improve health care and was established by
the AMA and ANA. The primary objective of
NJPC is to encourage greater cooperation be-
tween physicians and nurses.

The Nurses Association has under study now
a possible program that would provide special
training for nurses who would agree to gather
evidence in circumstances of alleged rape. Con-
ferences have been held with representatives
of the District Attorneys Association, OSMA,
officials at OUHSC and several Judges. There
are questions about the quality of the tes-
timony, the propriety of having nurses fill this
role and the extent treatment can be provided.
However, OSNA’s interest in this problem is
an indication of their willingness to assume
additional responsibilities.

SECTION VII

OCCUPATIONAL MEDICINE

It would be pleasant to report that the As-
sociation has made some progress in solving
occupational medicine problems. Last year
representatives of OSMA met with business
and industrial leaders in attempts to reach a
consensus on solutions that may have impact
on workmen’s compensation insurance rates
and Industrial Court awards. Those efforts
proved to be fruitless.

Oklahoma’s workmen’s compensation sys-
tem is one of the poorest in the United States.
Business and labor have been unable to rec-
oncile their differences and reach any com-
promises that would result in improvement.
We continue to have one of the highest rates in
the nation and lowest benefits. Physicians are
caught in the middle of the dilemma by being
responsible for medical reports that are used in
adversary proceedings. Recent publicity about
the Blackwell Zinc and Smelter Company indi-
cate the problems and bring unwarranted
criticism to the profession. The Oklahoma
Legislature has included in one workmen’s
compensation bill pending, provisions that
would require a fixed schedule for medical ser-
vices paid for by workmen’s compensation in-
surance. While this provision will probably be
deleted from the bill, it again points up the
disenchantment of some with the present sys-
tem.

It is difficult for the council to make any rec-
ommendations about workmen’s compensa-

280

tion. We have offered our services to all those
who are in a position to rectify the wrongs. !
About all we can do is continue to do so and
hope that needed changes will be made.

SECTION VIII

OPHTHALMOLOGY-OPTOMETRY

The Association finds itself in a real di-
lemma with relation to the profession of Op-
tometry. A lawsuit brought by the Board of Op-
tometric Examiners against a dispensing Opti-
cian in Shawnee has resulted in a Court ruling
that, among other things, would prohibit op-
ticians from using a keratometer or ophthal-
mometer. The ruling by the Court of Appeals is
being appealed to the Supreme Court. If the
Supreme Court takes jurisdiction, OSMA will
file an amicus curiae brief as authorized by the
House of Delegates last year. We have re-
cently, through OSMA’s Legislative Commit-
tee contacted Ophthalmologists about the law-
suit and the Court ruling to determine what
impact it could have on their profession if the
ruling is allowed to stand. It is anticipated that
some decision will be made during the Summit
meeting by Ophthalmologists.

A long term solution to the problem is either
licensing or certification of dispensing opti-
cians. This legislative solution, unless com-
promises can be worked out with the Optomet-
rists, would be a very difficult task. A bill has
been introduced and is being reviewed by
Ophthalmologists’ consultants, but there is lit-
tle chance it will be acted on this session of the
Legislature.

SECTION IX
GENERAL

The Association maintains liaison with the
professions of Osteopathy and Pharmacy
through other committees and organizations
than this Council. The by-laws for the Founda-
tion for Peer Review have been changed to ac-
commodate representation by the Osteopathic
profession. Through the Board of the Founda-
tion and through the staff of both organiza-
tions, continuing dialogue is maintained. We
have worked with OOA on several legislative
issues, most notably the Drug Substitution Bill
(HB 1160, see Legislative Committee Report)
and the Internship and Residency Bill (HB
1552). We have no significiant problems to re-
port.

Some pharmacists in the State (as well as
Oklahoma State Medical Association

some physicians) misinterpreted the
Association’s position on drug substitution. A
full report is contained in the Legislative
Committee’s Report (HB 1160). We have an ex-
cellent relationship with the Pharmacists of
the State and jointly we have worked to alter
rules and regulations promulgated by the
State Board of Narcotics and Dangerous
Drugs. We have also assisted the Pharma-
ceutical Association in the formation of the
plan to implement the drug vendor program
authorized by the Oklahoma Legislature and
administered by DISRS.

SECTION X
RECOMMENDA TIONS

This is an informational report to the House
of Delegates but it reflects the current rela-
tionship of OSMA with various organizations
and professional groups. In the event the
House of Delegates would suggest specific pro-
jects for the Council or alter the current ap-
proach taken to the stated problems, recom-
mendations should be included in the report of
the Reference Committee.

Report of the

COUNCIL ON PUBLIC HEALTH
(APPROVED)

Council Members

Schales L. Atkinson, MD, Oklahoma City,
Chairman

Charles E. Smith, Jr., MD, Oklahoma City
Glen L. Berkenbile, MD, Muskogee
Norman L. Haug, MD, Oklahoma City
C. Thomas Thompson, MD, Tulsa
Donald L. Cooper, MD, Stillwater
Henry D. Lagan, MD, Okeene
Leon Gilbert, MD, Bethany
Hayden H. Donahue, MD, Norman
Dan Keller, MD, Oklahoma City
Homer A. Ruprecht, MD, Tulsa
R. Leroy Carpenter, MD, Oklahoma City
Jim H. Earls, MD, Oklahoma City
Samuel Wheeler, MD, Oklahoma City

Alcoholism and
Drug Abuse Committee
Jim H. Earls, MD, Oklahoma City, Chairman
J. Hartwell Dunn, MD, Oklahoma City
E. Edwin Fair, MD, Ponca City
Donald L. Cooper, MD, Stillwater
Thomas M. Donica, MD, Oklahoma City

Journal / July 1975 / Volume 68

Ray V. McIntyre, MD, Kingfisher
Alfonso Paredes, MD, Oklahoma City
J. R. Drumwright, MD, Bartlesville
Twilah A. Fox, MD, Tulsa
Pamela R. Parrish, MD, Oklahoma City

Immunization Committee
Armond H. Start, MD, Oklahoma City, Chair-
man

John C. Kramer, MD, Tulsa
William L. Edwards, MD, Duncan
Harris D. Riley, Jr., MD, Oklahoma City
R. Leroy Carpenter, MD, Oklahoma City
Y. E. Parkhurst, MD, Miami
Burdge F. Green, MD, Stilwell
Delmar L. Gheen, Jr., MD, Tulsa
Ralph E. Murphy, MD, Ardmore
George Prothro, MD, Tulsa
James Mays, Jr., MD, Oklahoma City

Maternal Mortality Committee
Schales L. Atkinson, MD, Oklahoma City,
Chairman

Jed E. Goldberg, MD, Tulsa
James A. Merrill, MD, Oklahoma City
James R. McFarland, MD, Bartlesville
Max Deardorff, MD, Tulsa
Matthew B. Moore, MD, Tulsa
Sara De Persio, MD, Oklahoma City
J. W. McDoniel, MD, Chickasha
Paul A. BischofT, MD, Tulsa

Laboratory Quality Committee
Dan Keller, MD, Oklahoma City, Chairman
John F. DeJarnette, MD, Ponca City
J. William Hood, MD, Oklahoma City
E. Stanley Berger, MD, Oklahoma City
Dale E. VanWormer, MD, Tulsa
Robert L. Alexander, Jr., MD, Okmulgee
Byron F. Smith, MD, Oklahoma City
M. Boyd Shook, MD, Oklahoma City

Emergency Medical
Services Committee

Arthur F. Elliott, MD, Oklahoma City, Chair-
man

David J. Geigerman, MD, Oklahoma City
C. T. Thompson, MD, Tulsa
Howard B. Keith, MD, Shattuck
Gerald McCullough, MD, Norman

SECTION I
THE COUNCIL

While it can be stated that the Council on
Public Health was not "active” during the past

281

news

year, it must be realized that almost all ac-
tivities of the Oklahoma State Medical Associ-
ation are involved directly in the public health,
since that is the function of the practice of
medicine. The majority of this Council’s func-
tions are carried out through specialized com-
mittees. During the past year these commit-
tees have worked on a number of different pro-
jects.

SECTION II

COMMITTEE ON ALCOHOLISM
AND DRUG ABUSE

This committee’s "Drug Abuse Treatment
Manual” continues to be one of the most popu-
lar publications of the OSMA. Originally pub-
lished four years ago, it was republished last
year at the direction of the House of Delegates
and was up-dated to include new information
on drug abuse diagnosis and treatment, and a
list of the drug treatment and counseling agen-
cies available throughout the state.

Notice that the updated manual was given
throughout the state and to all members of the
Association. Subsequently, the OSMA has
again exhausted its supply of this publication.

The committee has continued to promote the
use of the 30 minute film entitled "What Did
You Take?”. This film was prepared in cooper-
ation with the New York Medical Society and
is designed to instruct physicians and other
emergency care personnel in the emergency
treatment of overdoses of heroin, barbituates,
amphetamines and LSD.

The film has proved to be popular with allied
health personnel, especially nurses and tech-
nicians working in emergency rooms. During
the past year it has been used an average of 4
to 6 times each month. Primarily it is being
shown at hospital staff meetings. However, on
a few occasions it has been shown to general
lay audiencbs. While the film is not really suit-
able for showing to the general public, its im-
pact cannot be denied.

The emphasis of this committee has shifted
during the past year. In years previous, most of
its activities had been related to drug abuse,
but in the past year they have been related to
alcoholism. The Oklahoma State Medical As-
sociation lent its name to a statewide confer-
ence on alcohol abuse and alcoholism, held in
the Center for Continuing Education in Nor-
man March 5-7 of this year.

282

The OSMA participated not only by lending
its name and promotional ability to the meet-
ing, it also participated in the design of the
program itself.

The committee also serves as a clearing
house for information on changes in The Con-
trolled Dangerous Substances Act that will be
of interest to physicians.

A recurring problem has been called to the
attention of the committee. This is a problem of
pharmacists being put in the position of having
to fill-in incompletely prepared prescriptions
written for controlled substances. The Con-
trolled Substances Act of 1970 holds the pre-
scibing practitioner responsible if the prescrip-
tion does not conform in all essential respects
to the regulations. Although the primary re-
sponsibility rests with the prescribing prac-
titioner, the pharmacist who receives an in-
completely prepared prescription is not specifi-
cally prohibited by the regulations from com-
pleting the prescription prior to filling it.

The regular completion of prescriptions,
however, must be discouraged. The physician
who makes a regular habit of issuing incom-
plete prescriptions is reminded of the prescrip-
tion requirements as set forth in the federal
regulations. In no case should a pharmacist ac-
cept a prescription for filling that does not bear
the patient’s name, the name of the drug pre-
scribed or the prescriber’s signature.

According to the Drug Enforcement Admin-
istration of the Department of Justice, "it
should not be necessary (for the pharmacist) to
complete the prescription information on more
than an occasional basis.”

SECTION III

COMMITTEE ON IMMUNIZATION

The primary purpose of this committee is to
advise the Department of Public Health on
questions of immunization and to assist them
in publicizing immunization campaigns and
schedules. During the past year, your commit-
tee has been active in both of these functions.

In August of 1974, the Oklahoma State De-
partment of Health, Immunization Program,
proceeded to update its immunization schedule
for the state. The recommendation had been
made that the poliomyelitis primary immuni-
zation section of the schedule for active im-
munizations be changed.

The American Academy of Pediatricians had
recommended that poliomyelitis primary im-

Oklahoma State Medical Association

munization . . . the primary series of three
be completed by the first year. The Oklahoma
Schedule had recommended three oral doses
. . . two doses eight weeks or more apart, and
a third 8-12 months or more after the second.
The underlined portion was the problem.
Health Departments across the country had
noted an extreme drop in the number of chil-
dren receiving this third dose. A survey taken
in Oklahoma revealed that many first graders
had never received the third oral dose.

Your committee voted to support the follow-
ing change in the Oklahoma schedule for ac-
tive immunization:

"Poliomyelitis — Primary immunization

"1. Infants — 8 weeks through 18 months: It
is strongly recommended that the primary
series of three doses of trivalent OPV be in-
itiated during the first six months of life and
completed by the first year. The basic series of
three oral doses of TOPV should be admin-
istered at 2, 4 and 6 months or at 8-week inter-
vals. A fourth dose of trivalent vaccine should
be given to all children at approximately 18
months of age.

"2. Children and adolescents through 18
years: It is strongly recommended that the
primary series of two doses of trivalent OPV be
administered at 8-week intervals, followed by
a third dose 6-months to one year later.”

The above change has now been made in the
Oklahoma Schedule. It also tends to couple the
poliomyelitis doses with the DPT injections.
Persons giving the immunizations can simply
be instructed to give the poliomyelitis dose at
the same time they give DPT.

This change has also made it easier for the
Health Department and the Department of
Education to enforce Oklahoma’s law requir-
ing certain immunizations for first-time school
entry. Technically a child that has not received
the three trivalent doses is not in compliance
with the law. However, it should be noted that
due to the many exclusions and some am-
biguity, the law is not "strictly” enforced.

During the past year, your Association also
participated in "Immunization Action Month.”
This was a major promotional campaign
scheduled for October of 1974. IAM, as it was
known, was directed on a national level by
the Center for Disease Control and in Okla-
homa by the Oklahoma State Department of
Health Immunization Program.

Your Association participated by issuing
news releases on IAM on its own letterhead

and distributing them to all newspapers, radio
and television stations in the state.

SECTION IV

MATERNAL MORTALITY COMMITTEE

Your committee has been very active during
the past year. Among other things, it has con-
sidered the publication of a "Maternal Health
Desk Book” for distribution to all hospitals
and, upon request, to physicians practicing ob-
stetrics.

The publication of the book was authorized
by the House of Delegates at its 1974 meeting.
The book outlines procedures to be followed
whenever a physician is faced with an ob-
stetrical emergency. The entire Maternal
Mortality Committee has undertaken a review
of material published in other states in order to
make any Oklahoma publication as complete
as possible.

For a number of years, your committee has
been concerned that the data it is collecting is
not being properly utilized. It has sought for
ways to publish case reports in the OSMA Med-
ical Journal that would not endanger the doc-
tor-patient relationship. The committee is now
in the process of establishing an exchange pro-
gram with Maternal Mortality Committees in
other states so that representative cases may
be printed in Oklahoma and vice versa. By not
revealing the state of origin of the case, and
requiring that the other state do the same, the
anonymity of all persons involved will be pro-
tected. At the same time, Oklahoma physicians
will gain the benefit of knowing what has hap-
pened in maternal mortality situations.

The Maternal Mortality Committee of the
OSMA and Oklahoma State Health Depart-
ment has always worked on a voluntary basis.
However, on occasion in the past the commit-
tee has been unable to receive the cooperation
of the physician involved in a maternal mortal-
ity. The necessary records and data regarding
the mortality were not made available to the
committee.

The committee is very cognizant of the fact
that its purpose is scientific and not punitive,
in nature. However, the committee cannot
ethically or morally turn away when it begins
to suspicion that something untoward is
happening. In order to assure itself that all
necessary information could be made avail-
able, your committee queried the Oklahoma
State Department of Health as to whether or

Journal / July 1975 / Volume 68

283

news

not the Commissioner of Health could grant
subpoena powers to the committee. A
memorandum regarding Oklahoma law on the
subject was prepared by an OSMA staff person
and forwarded to the legal section of the
Health Department. Legal counsel for the
Health Department concurred and on March 6
of this year, 1975, R. LeRoy Carpenter, MD,
Commissioner of Health for the state of Okla-
homa issued a letter of authorization to the
OSMA Maternal Mortality Committee. The
letter is as follows:

"This letter is to designate the Maternal
Mortality Committee as an official representa-
tive of the State Department of Health, to
carry out the duties pursuant to Title 63, Sec-
tion 1-106, Sub-Sections (b) (1) and (5), to make
investigations, inquiries and studies concern-
ing the causes of disease and causes of mortal-
ity in infants in the State of Oklahoma. The
Committee is further delegated the authority
as authorized to me (The Commissioner) under
Title 63, Section 1-106, Sub-section (7) to 'issue
subpoenas for the attendance of witnesses and
the production of books and records at any
hearing to be conducted by The Commissioner
or the State Board of Health.’ ”

Your Committee pledges that it will use this
subpoena power with much discretion and only
after all other avenues to obtain the necessary
information have been exhausted.

During the past year, a report was compiled
by the Maternal-Child Health Services Section
of the State Health Department on the deaths
studied by the Maternal Mortality Committee
from 1969 until 1972. A total of 51 deaths were
studied during that period of time. It was de-
termined that five of the deaths were due to
non-obstetrical causes, 14 to hemorrhages, 3 to
toxemia, 13 to sepsis and infection, 7 to embol-
isms and 9 to other causes, such as sickle cell
crisis, heaiT disease, cardiac arrest brought on
by hyperthyroidism, and acute cardiopulmon-
ary collapse.

One difficulty that the committee has en-
countered in the past was simply knowing
whether or not a death was pregnancy related.
The State Health Department Statistical Divi-
sion has been asked to include a question on
death certificates so that the attending physi-
cian at death can indicate whether or not the
deceased had been pregnant within 90 days
prior to death. This addition to the death
certificate will enable the committee to detect

284

maternal mortalities that in the past have
been masked by time.

One interesting statistic revealed by the
work done by the Maternal-Child Health Ser-
vice was the fact that deliveries by mid-wives
or non-professional persons have slowly been
increasing. From 2.5 per 1,000 births in 1970,
such deliveries reached 3.3 per 1,000 in 1973.
Although the rate is increasing slightly, it is
still less than half the rate of only 10 years ago
in 1965. In that year, 7.1 per 1,000 deliveries
was by a mid-wife or other person.

SECTION V.

COMMITTEE ON LABORATORY QUALITY

Your committee on Laboratory Quality con-
tinues to promote proficiency testing for physi-
cian office laboratories. Oklahoma, as one of
the first states in the nation to endorse and
promote such a program, has a long history of
effective participation in the College of Ameri-
can Pathologists-Proficiency Evaluation
Program. The 1975 PEP series allows 124
opportunities to evaluate the skills and com-
pare performance of the physician’s office lab-
oratory. Changed from 1974, the 1975 program
provided specimens 8 times a year rather than
quarterly as done in the past. Data accumu- j
lated in the PEP study is for the exclusive use
of the participants. However, statistics ob-
tained are published and anonymous copies of
the individual laboratory results are provided
the Committee for monitoring. The evaluation
report gives the Committee the opportunity for
individual or group analysis and permits the
isolation of an individual or group problems if
they exist. Fortunately, the physicians partici-
pating in PEP have improved the quality of
their laboratory work to the point that all are
providing quality laboratory services.

In 1974 there were 55 physician office lab-
oratories participating in the PEP Program. In
1975 there are only 25. Part of this decrease is
due to the fact that additional testing pro-
grams are available, the newest is a program
developed by the American Society of Internal
Medicine. The decrease is significant enough
that the Committee feels a survey should be
conducted among those physicians that are
most likely to perform laboratory work within
their offices to see if there is a reason for the
non-participation.

The Committee feels that a great deal of the
information that is accumulated as a result of

Oklahoma State Medical Association

the laboratory testing program could be used
in educational programs for physicians and
medical technicians. It is planned that after
the 1975 Series is complete an analysis of the
entire year’s results will be undertaken for the
purpose of writing papers to be presented at
various medical and medical technologists’
meetings.

Physicians should be aware there is growing
concern among governmental units about the
quality of services performed in physician of-
fice laboratories. Both California and Mary-
land require proficiency testing for physician
office laboratories and other states have con-
sidered similar legislation. We feel that volun-
tary participation in testing programs will
produce a higher quality of laboratory medi-
cine than would mandatory control. Because of
the record of participation by Oklahoma physi-
cians and the historical data available, we feel
we are justified in resisting efforts for a re-
quired testing program.

RECOMMENDA TIONS:

1. That the activities of the Committee be
continued;

2. That the Committee be permitted to run a
survey among physicians that are most likely
to have office laboratories to ascertain their at-
titude about the proficiency testing and the ne-
cessity for continued monitoring;

3. That the House of Delegates endorse the
concept of joint continuing education programs
between physicians and medical technicians.

SECTION VI
COMMITTEE ON

EMERGENCY MEDICAL SERVICES

During the waning days of the 34th Okla-
homa Legislature, lawmakers passed Senate
Joint Resolution 31 which set forth a state
question authorizing the creation of emergency
medical service boards and districts. If ap-
proved the district was authorized to vote up to
an 8 mill tax levy to purchase and maintain
emergency medical services. OSMA’s Legisla-
tive Committee supported passage of the res-
olution.

State Question 504, as the issue became
known, had strong support from some seg-
ments of the Oklahoma community, primarily
those communities which were without am-
bulance and emergency care facilities, or had a

Journal / July 1975 / Volume 68

limited program of such resources. Others op-
posed the issue on the grounds the recurring
tax levy was exorbitant, that the language of
the resolution was ambiguous and the EMS
Board structure was not equitable.

Your committee researched the issue care-
fully. We visited with Chamber of Commerce
representatives from the metropolitan cities,
we received input from the State Chamber,
Department of Health and Oklahoma Munici-
pal League. It was the Committee’s opinion
after hearing all the evidence, that State Ques-
tion 504 deserved the support of Oklahoma
physicians.

In early September the Chairman contacted
all newspaper editors in the state and indi-
cated the Association’s approval of the ques-
tion. Simultaneously, letters and fact sheets
went to all County Society Presidents and Sec-
retaries.

The issue received considerable editorial
support, including that of large Metropolitan
dailies. However, State Question 504 was de-
feated by a vote of 208,861 to 314,967.

It is interesting to study the support the
Question received. Even with organized
opposition, over 200,000 voters indicated that
EMS services in Oklahoma were inadequate, a
fact well known to the Committee, statistically
verifiable but unacceptable politically.

There are indications that Emergency Medi-
cal Services will receive higher priority rank-
ings in the future than in the past. A portion of
Governor Boren’s address to the Joint Legisla-
ture emphasized the financing of quality
emergency medical services. "... I will also
direct that emergency medical services be im-
proved in all geographical parts of the State. I
will use available federal highway safety funds
under the control of the Governor’s office to
support the training of ambulance crews and to
obtain radios and monitoring equipment for
emergency vehicles. Regardless of where they
live, all Oklahomans should be within minutes
of adequate health care . . .”

Representatives of the Governor’s office,
State Health Department and OSMA have col-
laborated on legislation that will help imple-
ment the Governor’s plan. Senate Bill 312
which will vest regulatory authority over
emergency medical services in the State Board
of Health has been introduced. The bill also
creates an Emergency Medical Services Ad-
visory Council to assist in carrying out the
provisions of the Act. If passed, the Council
will make recommendations to the State Board

285

news

of Health, for its approval or disapproval, re-
garding all facets of emergency medical ser-
vices, including but not limited to:

1. Qualifications for Certification of ambul-
ance personnel;

2. Patient care equipment for ambulances;
and

3. Communications equipment, local and
statewide.

Heretofore, these services have not been
regulated or coordinated by a state agency.

The Oklahoma Trauma Research Society
should receive a vote of confidence from the
House of Delegates. OTRS, with limited man-
power and funding, but with great support
from volunteer physicians has trained over
1,400 Emergency Medical Technicians (am-
bulance), 800 or more have qualified for na-
tional registry. More important than the
number is the fact that the technicians were
trained in 56 different communities, almost
entirely outside large metropolitan areas,
thereby insuring a better distribution of qual-
ified help. The Committee maintains close
liaison with OTRS and anticipates continued
support of their training program.

The State Department of Health has or-
ganized a special EMS division and has re-
cently completed and submitted to the De-
partment of Transportation, a comprehensive
Statewide Emergency Medical Service System
Plan. The plan did receive favorable consid-
eration but for several reasons did not get
funded. One overriding issue is the lack of
state regulations over EMS services. It is esti-
mated that 70% of Oklahoma’s ambulance ser-
vices operate with substandard vehicles, with-
out adequate personnel training, and lacking
the necessary equipment for life-saving proce-
dures. These conditions result in the estimate
that one of every four accident or sudden ill-
ness victims dies unnecessarily.

Faced with these problems, the Commis-
sioner of Health activated his Emergency Med-
ical Services Advisory Council in July of 1974.
EMSAC created by law in the 34th Oklahoma
Legislature has five OSMA members, most of
whom serve on this committee. Sub-
committees were formed and it was from one of
these (Sub-Committee on Legislation) that
came SB 312.

The Committee would like to express its ap-
preciation to the many physicians who are par-
ticipating in EMS activities. We mentioned

286

earlier the training program sponsored by
OTRS in 56 separate communities. In every
case, a local physician was involved as a coor-
dinator and in most cases as an instructor.
Oklahoma County physicians have organized
CORP — Central Oklahoma Rescue Patrol — for
the purpose of improving the Emergency Medi-
cal System in Oklahoma City. CORP, which
was recently incorporated, will launch an area-
wide education program on cardiopulmonary
resuscitation.

Public Law 92-641 — The National Health
Planning and Resources Development Act of
1974 (See Board of Trustees Report) could have
a major impact on emergency medical services.
Plans now under scrutiny by Governor Boren
could result in multiple health planning dis-
tricts in Oklahoma. Each district will have al-
most autonomous control over the planning
and implementation of health programs, in-
cluding EMS systems. It is important that if
the multiple district option is chosen, that
physicians at the local level influence health
planning to insure statewide coordination.
SUMMARY

Reviewing past activities, current programs
and future plans, it appears that Emergency
Medical Services in Oklahoma are destined for
improvement. The vote on State Question 504
indicates there is a broad segment of the
populace concerned about the availability of
emergency services; efforts by Governor Boren,
the Legislature and the State Health Depart-
ment could result in some supervisory author-
ity and better funding; support communities
have given the OTRS program and the great
interest shown by physicians all lead to the
conclusion that finally, proper emphasis is
being placed on Emergency Medical Services.
RECOMMENDATIONS:

1. The House of Delegates approve the con-
cept of a statewide coordinated Emergency
Medical Services System;

2. The House of Delegates encourage OSMA
members to participate in the planning and
implementation of programs to improve
Emergency Medical Services.

Report of the

COUNCIL ON SOCIO-ECONOMIC
ACTIVITIES
(APPROVED)

Council Members

Roger J. Reid, MD, Ardmore, Chairman
Charles Bodine, MD, Oklahoma City

Oklahoma State Medical Association

Thurman Shuller, MD, McAlester
Roger Haglund, MD, Tulsa
Ed L. Calhoon, MD, Beaver
Robert Sukman, MD, Oklahoma City
Arthur E. Schmidt, MD, Oklahoma City
Ann K. Kent, MD, Muskogee
Walter E. Brown, MD, Tulsa
Howard B. Keith, MD, Shattuck
Robert R. Dugan, MD, Oklahoma City
Harold Stout, MD, Waurika

Peer Review Committee A
Edward L. Moore, MD, Tulsa, Chairman
Tony Puckett, MD, Oklahoma City
Robert M. Shepard, Jr., MD, Tulsa
Samuel A. Wheeler, MD, Oklahoma City
Richard G. Dotter, MD, Oklahoma City
John A. McIntyre, MD, Enid
Leonard H. Brown, MD, Tulsa
Worth M. Gross, MD, Tulsa
Joseph Messenbaugh, MD, Oklahoma City
Jack L. Richardson, MD, Tulsa
Frank L. Adelman, MD, Enid
Bobby Gene Smith, MD, Oklahoma City
Samuel C. Jack, MD, Lawton
Roger Haglund, MD, Tulsa
William R. McShane, MD, Tulsa
Charles R. Gibson, MD, Chickasha

Peer Review Committee B
Edward L. Moore, MD, Tulsa, Chairman
Arthur E. Schmidt, MD, Tulsa
William E. Hood, MD, Oklahoma City
David D. Rose, MD, Ardmore
Alfred H. Bungardt, MD, Tulsa
Bill G. Henley, MD, Lawton
Richard M. Taliaferro, MD, Ada
David B. Brinker, MD, Oklahoma City
Michael Berkey, MD, Tulsa
Joseph Salamy, MD, Tulsa
Neil B. Kimerer, MD, Oklahoma City
Leon Combs, MD, Shawnee
Thomas Henley, MD, Oklahoma City
S. Fulton Tompkins, MD, Oklahoma City
William J. Forrest, MD, Oklahoma City
Schales Atkinson, MD, Oklahoma City
Victor L. Robards, Jr., MD, Tulsa

Peer Review Consultants
Robert Morgan, MD, Oklahoma City
Kent Braden, MD, Oklahoma City
Robert L. Imler, Jr., MD, Tulsa
William B. Renfrow, MD, Oklahoma City
L. Chester McHenry, MD, Oklahoma City
Lyle W. Burroughs, MD, Oklahoma City

Journal / July 1975 / Volume 68

Charles J. Wine, MD, Oklahoma City
A. Manson Fuller, MD, Tulsa
Gerald W. Boles, MD, Oklahoma City
Thomas L. Ashcraft, MD, Tulsa

SECTION I
THE COUNCIL

The Council has been assisted throughout
the year by able committees operating under
its jurisdiction, and the Council per se has had
no matters referred to it which required its di-
rect involvement.

Peer Review Committee

In 1966, following the enactment of Medi-
care, the OSMA established a Peer Review or
Insurance Review Committee. The purpose of
the committee throughout the years has been
to adjudicate claims involving health programs
which reimburse physicians according to
"usual, customary and reasonable” fee.

Over the years, the structure and the organi-
zation of the committee has changed. In 1966 it
started as a single committee that met on call
of the Chairman. As the number of cases began
to increase, it was necessary for the committee
to meet monthly. Because of an increased case
load, two years ago it became necessary to split
the committee into two sub-committees, each
with its own chairman, to meet on alternate
months. In addition, a consultation or consul-
tant sub-committee was established to assist
either of the two sub-committees whenever a
claim came up involving one of the specialties
or sub-specialties not represented on the main
committee.

The committee’s name was changed three
years ago from"Medical Insurance Review” to
"Peer Review” by the House of Delegates. Its
purpose, however, remained the same. As
stated in the Peer Review function adopted by
the House, the Committee ". . . shall serve the
function of seeking the objective reconciliation
of unusual medical insurance claims involving
members of the OSMA and health insurance
coverages which offer payment of customary
and reasonable fees.”

During the last year, the committee adopted
a new "OSMA Peer Review Summary” form so
that it might streamline its operation. The
rules of the committee require that each person
filing a case for hearing must fill out the sum-
mary form as completely as possible.

It should be understood that the term "case”

287

news

as used in this report does not necessarily
mean that the committee considered only a
single claim, or a single charge. In many cases,
numerous claims were involved. Although the
total amount of money in controversy in any
one case might not be much, the case could
establish a precedent for the insurance com-
pany or carrier to follow in the future. As an
example, if the committee recommends that
the carrier recognize a higher fee for a given
procedure, that recommendation will affect not
only the outcome of the case in question, but all
other charges received for the same procedure
by that carrier.

From June 1, 1974 to March 31, 1975, the 30
members of the two Peer Review Sub-
committees had reviewed 169 cases, some in-
volving multiple charges and/or multiple pa-
tients.

Of the 169 cases considered, 84 involved
Oklahoma Blue Shield. Medicare accounted for
19 cases, the Department of Institutions, Social
and Rehabilitative Services had 28 cases, and
private insurance companies accounted for 37.

Resolution No. 1
(DISAPPROVED)

INTRODUCED BY: Oklahoma County Medi-
cal Society

SUBJECT: Insurance Claim Forms
REFERRED TO: Reference Committee No. I

WHEREAS, almost every insurance com-
pany has a different and unique insurance
claim form, but requiring almost essentially
the same information in all instances; and

WHEREAS, the physicians of Oklahoma are
asked to fill out all the different types of forms,
requiring extensive time and expense; there-
fore be it

RESOLVED, that the physicians of Okla-
homa be encouraged to use the American Med-
ical Association’s Uniform Claim Form for all
accident and health insurance reports; and be
it further

RESOLVED, that if an individual insurance
company requires its own claim form to be
filled out, an appropriate charge be made to the
insurance company as reimbursement to the
physician for his time and inconvenience.

Resolution No. 2
(DISAPPROVED)

INTRODUCED BY: Carter, Love Marshall
Counties Medical Society
SUBJECT: Proposed Amendments to the
By-Laws of the Oklahoma State Medical
Association.

REFERRED TO: Reference Committee No. I
It is proposed that Chapter I, Section 1.00 of
the Oklahoma State Medical Society By-Laws
be amended as follows: The last sentence in the
paragraph which now reads "All members of
component societies and of this association are
required to belong to the American Medical
Association” shall be amended to read as fol-
lows: "Members of the Oklahoma State Medi-
cal Society and component county societies are
not required to belong to the American Medical
Association, but each member may at his op-
tion elect to assume membership in the Ameri-
can Medical Association.”

It is also proposed that Chapter II, Section
2.00 shall be amended to read as follows:
"American Medical Association Dues. Mem-
bers of the Oklahoma State Medical Society
are not required to belong to the American
Medical Association. For those members who
voluntarily elect to assume membership in the
American Medical Association, those dues and
assessments shall be collected and remitted in
the manner provided by the by-laws of the
American Medical Association.”

It is also proposed that Chapter V, Section
7.036 of the Oklahoma State By-Laws be
amended as follows: "Appeals to the American
Medical Association. Judicial decisions of the
Board of Trustees which affect members of the
American Medical Association may be ap-
pealed to the Judicial Council of the American
Medical Association in accordance with that
organization’s constitution and by-laws. In
such event the decision of the Board of Trus-
tees shall not be suspended pending the appeal
to the American Medical Association Judicial
Council. Members of the Oklahoma State Med-
ical Association who elect not to become mem-
bers of the American Medical Association, may
not appeal adverse judicial decisions to the
American Medical Association.”

Resolution No. 3
(DISAPPROVED)

INTRODUCED BY: Tulsa County Medical
Society

SUBJECT: Repeal of the Provisions in the
By-Laws of Oklahoma State Medical As-

288

Oklahoma State Medical Association

sociation Requiring Membership in Ameri-
can Medical Association.

REFERRED TO: Reference Committee No. I
WHEREAS, Oklahoma State Medical As-
sociation is one of only seven state medical as-
sociations requiring its members to be mem-
bers of American Medical Association; and
WHEREAS, Referendums conducted by
Oklahoma State Medical Association in recent
years indicate a growing and substantial
number of its members object to the compul-
sory aspects of AMA membership; therefore be
it

RESOLVED, that the OSMA House of Dele-
gates, acting at the annual meeting of April
23-26, 1975, approve appropriate amendments
to the By-Laws of Oklahoma State Medical As-
sociation to delete the requirement that its
members be members of American Medical As-
sociation; and be it further

RESOLVED, that the Oklahoma State Med-
ical Association urge its members to vol-
untarily be members of American Medical As-
sociation.

Recommended Amendments to Complete
the Objectives of Resolution No. 3

It is proposed that Chapter I, Section 1.00 of
the By-Laws be amended as follows:

The last sentence in the paragraph, which
now reads "All members of component societies
and of this association are required to belong to
American Medical Association,” shall be
amended to read as follows: "Members of this
association are not required to belong to
American Medical Association, but each
member at his option may elect to assume
membership in American Medical Associa-
tion.”

It is further proposed that Chapter II, Sec-
tion 2.00 shall be amended to read as follows:
"Section 2.00. AMERICAN MEDICAL AS-
SOCIATION DUES. Members of this associa-
tion are not required to belong to American
Medical Association. For those members who
voluntarily elect to assume membership in
American Medical Association, AMA dues and
assessments shall be collected and remitted in
the manner provided by the By-Laws of the
American Medical Association.”

It is further proposed that Chapter V, Sec-
tion 7.036 of the By-Laws shall be amended to
read as follows:

"7.036. APPEALS TO AMERICAN MEDI-
CAL ASSOCIATION. Judicial decisions of the
Board of Trustees which affect members of the

American Medical Association may be ap-
pealed to the Judicial Council of the American
Medical Association in accordance with that
organization’s Constitution & By-Laws. In
such event the decision of the Board of Trus-
tees shall not be suspended pending the appeal
to the AMA Judicial Council. Members of the
Oklahoma State Medical Association who elect
not to become members of the American Medi-
cal Association, may not appeal adverse deci-
sions to the American Medical Association.”

ResolutionNo. 4
(APPROVED)

INTRODUCED BY: Tulsa County Medical
Society

SUBJECT: Support of Emergency Medical
Services Systems.

REFERRED TO: Reference Committee No. Ill
WHEREAS, the Emergency Medical Ser-
vices System is a vital component of the health
care delivery system; and

WHEREAS, both professionals and lay per-
sons recognize the inadequacies in many areas
of the present Emergency Medical Services
System; and

WHEREAS, the physician plays a vital role
in the design and implementation of
Emergency Medical Services Systems; and
WHEREAS, the Oklahoma State Medical
Association recognizes the desirability of
physician participation in the training of
Emergency Medical Technicians and other al-
lied health personnel for improving the deliv-
ery of Emergency Medical Services; therefore
be it

RESOLVED, that the Oklahoma State Med-
ical Association support the concept of a com-
prehensive system of Emergency Medical Ser-
vices, and that physicians evidence their sup-
port by participation in activities of design and
development of Emergency Medical Services
Systems; and be it further

RESOLVED, that physicians support and
participate in the training of Emergency Medi-
cal Technicians and other allied health per-
sonnel in the delivery of such services; and be
it further

RESOLVED, that physicians participate in
the assurance of the capability of hospitals to
deliver quality emergency care; and be it
further

RESOLVED, that Oklahoma State Medical
Association urge other health professional or-

Journal / July 1975 / Volume 68

289

news

COUNCIL ON INSURANCE)

ganizations to resolve their support of such
Emergency Medical Services Systems.

Resolution No. 5
(DISAPPROVED FOR
SUBSTITUTE RESOLUTION)

INTRODUCED BY: Kingfisher County Medi-
cal Society

SUBJECT: Small Hospital PSRO Problems
REFERRED TO: Reference Committee No. Ill
WHEREAS, the new utilization review regu-
lations pertaining to Medicare and Medicaid
has placed an unacceptable manpower problem
on the small hospitals of the State of Okla-
homa; and

WHEREAS, the continued operation of this
pernicious law will lead to the closure and fi-
nancial crippling of many small Oklahoma
hospitals; therefore be it

RESOLVED, that the Oklahoma State Med-
ical Association recommends that PSRO excep-
tion be granted to hospitals with ten or fewer
active medical staff members, and that the
Oklahoma Congressional Delegation be
petitioned by OSMA to introduce legislation ef-
fecting this exception.

Resolution No. 6
( DISAPPROVED )

INTRODUCED BY: Kingfisher County Medi-
cal Society

SUBJECT: Voluntary Association Member-
ship

REFERRED TO: Reference Committee No. I
WHEREAS, the officers of many organiza-
tions tend to ignore a captive audience; and
WHEREAS, the American Medical Associa-
tion has exhibited a considerable indifference
to the desires and ideals of the average U.S.
physician; and

WHEREA&, the American Medical Associa-
tion has failed to exhibit expected financial
prudence; therefore be it

RESOLVED, that the Oklahoma State Med-
ical Association change its constitution to
permit membership in the State and County
Societies without mandatory membership in
the American Medical Association, effective
January 1, 1975.

Resolution No. 7
(REFERRED TO THE

INTRODUCED BY: Kingfisher County Medi-
cal Society

SUBJECT: Release of Information to Third
Party Carriers

REFERRED TO: Reference Committee No. II
WHEREAS, with continued encroachment of
third party carriers into confidential medical
records justifying according to their needs
either insurability of a patient or if a claim is
properly covered by them; and

WHEREAS, the third party uses a blanket
release of information signature of the patient
they acquired upon issuing said policy which
may be months to years previous; and

WHEREAS, information obtained from the
doctors’ clinical notes may be differential diag-
nosis only and not a proven diagnosis requiring
further diagnostic procedure; and

WHEREAS, this information labeled "pre-
existing illness” may be used without further
proof of diagnosis from other physicians and
also not allowing further recourse by the pa-
tient; and

WHEREAS, most reputable insurance com-
panies already require complete physical ex-
amination by physicians before life or health
insurance is obtained; therefore be it

RESOLVED, the Oklahoma State Medical
Association is opposed to medical record
"snooping” by third party carriers, unless such
information is asked by the physician giving
said applicant the insurance physical so as to
complete his insurance report concerning in-
surability and that the Oklahoma State Medi-
cal Association is strongly opposed to medical
record "snooping” after a claim has been filed
to try to prove pre-existing illness.

Resolution No. 8
( REFERRED TO THE
COUNCIL ON INSURANCE)

INTRODUCED BY: Kingfisher County Medi-
cal Society

SUBJECT: Pre-existing Illnesses
REFERRED TO: Reference Committee No. II
WHEREAS, it is frequently the case that the
patient purchases health or life insurance and
maintains this insurance in force, through
payments for many years; and

WHEREAS, it frequently occurs that pa-
tients find out after the fact or after the illness
that the insurance will not pay because of a
"pre-existing condition”; and

290

Oklahoma State Medical Association

WHEREAS, the patient has, over a long
period of time, made payments in good faith
with the expectation that the illness, injury or
et cetera will be covered, only to find out after
the fact that this particular problem is ex-
cluded under the "pre-existing illness”; there-
fore be it

RESOLVED, that the insurance committee
of the Oklahoma State Medical Association be
instructed to see that legislation is introduced
and vigorously worked for the passage of legis-
lation, requiring all insurance companies
operating within the State of Oklahoma, to
notify their clients either prior to the issuance
of a policy or very shortly thereafter in very
clear and concise terms, the exact extent of
coverage and conditions and/or situations
under which the insurance will not be applica-
ble.

Resolution No. 9
( APPROVED )

INTRODUCED BY: Kingfisher County Medi-
cal Society

SUBJECT: Repeal of HEW’s Professional
Standards Review Organization
REFERRED TO: Reference Committee No. Ill
WHEREAS, PSRO violates the confidential-
ity between the patient and physician; and
WHEREAS, PSRO increases the expense of
hospital care to the patient who has to absorb
the administrative cost for carrying out the re-
views as stipulated by the legislation; and
WHEREAS, the present PSRO legislation
opens up avenues for other regulatory controls
such as the utilization review changes made
for Medicare and Medicaid patients; and
WHEREAS, PSRO establishes guidelines
based on statistical data rather than on actual
patient outcome; therefore be it
RESOLVED that HEW’s Professional
Standards Review Organization law be re-
pealed and that this stand for repeal be
adopted by the Oklahoma State Medical As-
sociation.

Resolution No. 10
(DISAPPROVED FOR
SUBSTITUTE RESOLUTION)

INTRODUCED BY: Kingfisher County Medi-
cal Society

SUBJECT: Non-compliance with Utilization
Review Regulations

REFERRED TO: Reference Committee No. Ill
WHEREAS, the Federal regulations on
Utilization Review of Medicare and Medicaid
cases have become progressively more repres-
sive; and

WHREAS, the last edition of these regula-
tions, proclaimed in November of 1974 to be-
come effective February 1, 1975, actually will
cause a deterioration of medical care, com-
promise the confidentiality of the patient, and
impose a nonproductive paperwork task on the
overworked physician; and

WHEREAS, the American Medical Associa-
tion is now suing the government on the con-
stitutionality of these pernicious regulations;
therefore be it

RESOLVED, that the Oklahoma State Med-
ical Association recommend that those of its
membership on hospital staffs not comply with
these regulations, and that the Congressional
delegation be notified of this recommendation.

Resolution No. 11
(DISAPPROVED)

INTRODUCED BY: Comanche-Cotton-

Tillman County Medical Society
SUBJECT: Collective Bargaining By the AMA
REFERRED TO: Reference Committee No. Ill
WHEREAS, the American Medical Associa-
tion has failed to adequately represent the ma-
jority of its members in the recent past with its
present leadership and as it is currently or-
ganized; therefore be it

RESOLVED, that the next national meeting
of the AMA devote as much time as is neces-
sary to either change the constitutional struc-
ture of the AMA or to add a division of the
AMA to allow its members to be represented by
an effective collective bargaining agent to deal
with all organizations involved in health care;
and be it further

RESOLVED, that this action has not been
taken by choice, but has been forced upon the
medical profession by recent and current ac-
tions of the political leadership of the United
States.

Resolution No. 12
(APPROVED AS
EDITORIALLY AMENDED)

INTRODUCED BY: Oklahoma County Medi-
cal Society

SUBJECT: AMA Publications

Journal / July 1975 / Volume 68

291

news

REFERRED TO: Reference Committee No. I
WHEREAS, the American Medical Associa-
tion has found itself in a financially embar-
rassing position and, therefore, has found it
necessary to assess AMA members $60, which
assessment has resulted in the loss of many
AMA members over the country; and

WHEREAS, the AMA publishes numerous
specialty journals, magazines, and other inci-
dental publications, that have resulted in a
loss of nearly $5.5 million per year when these
were distributed free of charge or at a nominal
subscription rate to its members; and

WHEREAS, it has been learned from inter-
views throughout the country that most of
these publications are not being utilized by
AMA members, therefore be it

RESOLVED, that the Oklahoma State Med-
ical Association urge the American Medical
Association to discontinue, immediately, free
distribution of all publications, except for
JAMA; and be it further

RESOLVED, that the AMA establish a sub-
scription price that will pay for its other publi-
cations, or, if such a subscription price is not
feasible, that it discontinue, immediately, the
publication of specialty journals, Prism, and all
other magazines, leaflets, and brochures not
fiscally sound.

Resolution No. 13
(DISAPPROVED FOR
SUBSTITUTE RESOLUTION)

INTRODUCED BY: Oklahoma County Medi-
cal Society

SUBJECT: Non-participation in Utilization
Review Regulations

REFERRED TO: Reference Committee No. Ill
WHEREAS, the published regulations ap-
pearing in the Federal Register November 29,
1974, implementing utilization review are in-
consistent ;with good patient care, infringe on
the doctor/patient relationship, threaten the
confidentiality of that relationship, promul-
gate the deterioration of quality medical care,
pose the potential threat of closing many hos-
pitals and threaten our patients with possible
loss of hospital privileges and financial assis-
tance, therefore be it

RESOLVED, that the physicians of the state
of Oklahoma elect a position of non-
participation in the utilization review reg-
ulations.

292

(APPROVED AS AMENDED AS
SUBSTITUTE RESOLUTIONS)

INTRODUCED BY: Kingfisher County Medi-
cal Society

SUBJECT: Non-participation in Utilization
Review

REFERRED TO: Reference Committee No. Ill
WHEREAS, the published regulations ap-
pearing in the Federal Register on November
29, 1974, implementing Utilization Review are
inconsistent with good patient care, infringe on
the doctor-patient relationship, constitute un-
solicited and therefore unethical consultation,
threaten the confidentiality of that rela-
tionship, promulgate the deterioration of qual-
ity medical care, pose the potential threat of
closing many hospitals and threaten our pa-
tients with possible loss of hospital privileges
and financial assistance; and
WHEREAS, Peer Review and Utilization
Review have been traditionally performed by
the profession to assure quality medical care,
not cost control, and is best handled at the local
level so that it can take into consideration local
problems; and

WHEREAS, any nationwide method of
Utilization Review must necessarily ignore
such local problems and cannot be accurately
varied into size of hospital facility or medical
staff; and

WHEREAS, any such national scheme will
result only in a rationing of health care ser-
vices to patients; therefore be it

RESOLVED, that the physicians of the State
of Oklahoma vigorously support the American
Medical Association’s lawsuit against these
onerous regulations, and, therefore be it
RESOLVED, that the physicians of the State
of Oklahoma will continue Utilization Review
and Peer Review on an individual hospital
basis, and will not participate in Utilization
Review as outlined in the above cited reg-
ulations, and

Oklahoma State Medical Association

regulations as currently published, and there-
fore be it further

RESOLVED, that the Oklahoma State Med-
ical Association seek the broadest possible base
of support in such a campaign by inviting
another cooperative physician by other state
medical associations throughout the United
States.

(Late Resolution)

INTRODUCED BY: William Gamier, MD, and
Sidney Williams, MD

SUBJECT: Eyeglass Prescriptions from Oph-
thalmologists

REFERRED TO: Reference Committee No. Ill
WHEREAS, Section 7, Number 490 of the
Opinions and Reports of the Judicial Council of
the American Medical Association (1966) enti-
tled ''Right of Patient to Copy of Prescription”,
states: ''A patient is entitled to a copy of his or
her prescription for glasses, drugs, or ap-
pliances and he has the privilege of having the
prescription filled wherever he wishes, (Judi-
cial Council 1963)”; and
WHEREAS, the peculiarities of Oklahoma
State Law place an extraordinary burden upon
the ophthalmologists who issue such a prescrip-
tion by holding him responsible (in Title 59,
Section 942 of the Oklahoma Statutes) for the
"full effect” of any eyeglasses furnished in re-
sponse to that prescription, no matter who fur-
nishes them; and

WHEREAS, this extraordinary responsibil-
ity imposes a liability upon the ophthal-
mologists unlike the liability imposed by pre-
scriptions for medication; therefore be it
RESOLVED, that the Oklahoma State Med-
ical Association House of Delegates recognize
that there is not an ethical admonition on the
part of an ophthalmologist to release an eye-
glass prescription to a patient unless he wishes
to do so and is satisfied that it will be filled in a
correct and non-harmful manner.

Resolution No. 14
( APPROVED AS AMENDED
AS SUBSTITUTE RESOLUTION)

INTRODUCED BY: William Gamier, MD, and
Sidney Williams, MD

SUBJECT: Eyeglass Prescriptions from Oph-
thalmologists

REFERRED TO: Reference Committee No. Ill
WHEREAS, Section 7, Number 490 of the
Opinions and Reports of the Judicial Council of

the American Medical Association (1966) enti-
tled "Right of Patient to Copy of Prescription”,
states: "A patient is entitled to a copy of his or
her prescription for glasses, drugs, or ap-
pliances and he has the privilege of having the
prescription filled wherever he wishes, (Judi-
cial Council 1963)”; and
WHEREAS, the peculiarities of Oklahoma
State Law place an extraordinary burden upon
the ophthalmologists who issue such a prescrip-
tion by holding him responsible (in Title 59,
Section 942 of the Oklahoma Statutes) for the
"full effect” of any eyeglasses furnished in re-
sponse to that prescription, no matter who fur-
nishes them; and

Resolution No. 15
(APPROVED)

INTRODUCED BY: Medical Center Liaison
Committee and the Legislative Committee
SUBJECT: Study of OU College of Medicine’s
Admission Policy

REFERRED TO: Reference Committee No. II
WHEREAS, at the present time there is con-
cern that admission policies of the University
of Oklahoma College of Medicine are not
equitable for the entire State of Oklahoma; and
WHEREAS, the selection of students may
have a beneficial effect on the distribution of
physicians in the State, especially in the rural
areas of Oklahoma, now experiencing an acute
shortage of medical personnel; and
WHEREAS, in order to better serve all the
people of Oklahoma with good medical care it
appears that it is in the best interest of the
State to have all geographic regions of the
State proportionately represented on the Board
of Admissions; and

WHEREAS, the Oklahoma Legislature has
under consideration, a Senate Resolution that
wTould mandate the composition of the College
of Medicine’s Board of Admissions; and
WHEREAS, the composition of the Board of
Admissions of the Oklahoma University Col-
lege of Medicine and the policies whereunder it
operates has and is a major concern to practic-
ing physicians of the State of Oklahoma;

Journal / July 1975 / Volume 68

293

news

NOW, THEREFORE, BE IT RESOLVED by
the House of Delegates of the Oklahoma State
Medical Association, duly assembled:

SECTION 1. (A) That the Chairman of the
Board of Trustees of the Oklahoma State Medi-
cal Association, with the concurrence of the
Presidents of County Medical Societies within
each district, appoint forthwith, two physicians
from each of Oklahoma’s six Congressional
Districts to serve on a special study committee.

(B.) That the Provost of the University of
Oklahoma Health Sciences Center be re-
quested to appoint five physicians representing
the faculty and staff of the Oklahoma Univer-
sity College of Medicine to likewise serve on
the Committee.

SECTION 2. That the above established
Committee convene as often as necessary to
study in depth, the admissions policies of the
Oklahoma University College of Medicine and
the effect said policies have on the distribution
of physicians in Oklahoma;

SECTION 3. That a full report of the finding
of the Committee be filed with the Executive
Committee of the Oklahoma Legislative Coun-
cil at least 30 days prior to the convening of the
2nd Session of the 35th Oklahoma Legislature.

SECTION 4. That duly authenticated copies
of this Resolution, signed by the Speaker of the
House of Delegates shall be transmitted forth-
with, to the Governor of the State of Okla-
homa, President Pro Tempore of the Oklahoma
Senate, Speaker of the Oklahoma House of
Representatives and the Provost of the Okla-
homa University Health Sciences Center.

SECTION 5. That copies of this Resolution
be transmitted to all members of the Okla-
homa State Senate and the Oklahoma House of
Representatives.

SECTION 6. That the findings of the report
be published in The Journal of the Oklahoma
State Medical Association.

SECTION 7. That the Medical Center
Liaison Committee report the results of the
Committee’s findings to the House of Delegates
at the next annual meeting.

(Late Resolution)

Resolution No. 16
(DISAPPROVED)

INTRODUCED BY: Kent Braden, MD
SUBJECT: Physician-Patient Relationship
REFERRED TO: Reference Committee No. Ill

294

WHEREAS, even though we, as physicians,
face the eleventh hour, it is not too late for us I
to guide our own destiny.

We have seen our image decline, the inci-
dence of malpractice claims rise, and ever in-
creasing amounts of our time consumed by
nonsensical clerical servitude and meaning-
less monotonous meetings. This demise and
debacle began simultaneously with the first
acceptance of a third party intermediary,
thereby breaching the foundation of our pro-
fession — the doctor-patient relationship.

What may have initially been an unwitting
endeavor progressed to a willing participation
and then catapulted to a subservience, and al-
most extinction of the noblest of professions.
The pot of porridge has long since run dry and
we now face the reality of a hired employee who
is unhappy with his job.

We have tried in vain to persuade, to educate
and to reason with all third parties. We have
striven to stem the tide of the decline of the
greatest health care system the world has ever
known. In our anguish we have overlooked a
very simple truth. When an employee can no
longer tolerate his job, he should resign. It is
time we relinquished our job as providers for
consumers and returned to our profession as
physicians caring for patients.

We have too long been coerced into a position
of interpreters and enforcers for third parties
by our secretarial completion of forms, and
thus invoked the wrath of both our patients
and third parties.

We have too long labored under the daily
dread and fear of malpractice claims.

As physicians, we are the first to admit, as
humans, we have malperformers in our ranks.
No other profession is as anxious to promote
the continued quality and advancement of
knowledge and care as we. We have long per-
formed peer services and need to constantly
seek to further improve our peer structure.

The time has now come to stand on the cour-
age of our convictions — or sink into the mire
of mediocrity. If we fail at this time to return
to the principles that have so long sustained
our profession; if we refuse to assert our rights
— then let us henceforth be silent. He who will
not stand to fight for what is right should not
stand to speak.

BE IT THEREFORE RESOLVED, that

(1) The physicians of OSMA shall accept
payment from no one — NO ONE - except
their patients and/or their families.

(2) The physicians of OSMA shall render to

Oklahoma State Medical Association

patients an itemized bill listing in detail all
charges for tests, surgeries, etc. with dates and
diagnosis and shall sign same, but will fill out
no other forms of any description.

(3) The physicians of OSMA shall deal pro-
fessionally directly only with their patients,
thereby taking a stand of non-participation in
utilization review, PSRO, National Health In-
surance or any other ill-conceived plan devised
by a third party which would appear to be det-
rimental to quality health care.

(4) The Board of Trustees shall perform or
appoint a committee to perform, the planning
of review boards to render judgment affecting
the legitimacy of malpractice claims.

(5) The Board of Trustees shall perform or
appoint a committee to perform, the structure
of a simple, but effective, guideline for improv-
ing peer review.

(6) The Board of Trustees shall perform or
appoint a committee to perform, a standardized
pamphlet to be used by all physicians of OSMA
explaining to patients our procedures and the
reasons, and inviting them to inquire about
and discuss any and all fees at their pleasure.

BE IT FURTHER RESOLVED, that copies
of this Resolution be distributed to every
member of the Oklahoma Medical Association
and that it be published in the official publica-
tions of the Association. □

LOOK AHEAD —

MARK YOUR CALENDAR NOW!
OKLAHOMA MEDICAL SUMMIT 76

May 5th, 6th, 7th, 8th, 1976
Lincoln Plaza Forum
Oklahoma City, Oklahoma

Again in 1976, this will be a combined meeting of the Oklahoma State Medical
Association, the Oklahoma City Clinical Society and the Oklahoma Academy of
Family Physicians.

Journal / July 1975 / Volume 68

295

August

1975

Vol. 68, No. 8

of the Oklahoma State Medical Association

EDITORIAL BOARD

MARK R. JOHNSON, MD
Editor-in-Chief

CONTENTS

HARRIS D. RILEY, Jr., MD
Editor

ROBERT G. TOMPKINS, MD
Editor

editorial

Education of the Coming Generation of Physicians 297
President’s Page ....... 298

ERNEST LACHMAN, MD
Corresponding Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

scientific

Community Genetics I, James G. Coldwell, MD, Bur-

han Say, MD and Kathryn Jones, BS . . 299

OFFICERS

ARNOLD G. NELSON, MD
President

WILLIAM M. LEEBRON, MD
Vice-President

HAVEN W. MANKIN, MD
Secret a ry-Treasurer

STAFF

DON BLAIR
Business Manager

LOUISE MARTIN
Editorial Assistant

SUBSCRIPTION TO THE JOURNAL is in-
cluded in membership fees. Other subscrip-
tions are $6.50 per year or $1.00 per copy
with each request subject to approval of the
Editorial Board.

POSTMASTERS: Send all change of address
notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

special

Projecting the Estimated Needs for Internists in
Oklahoma Through the Year 1990, A task force
report of the Oklahoma Society of Internal Med-
icine ......... 308

News from the Oklahoma State Department of

Health 311

news

A Summary of Medical Legislation Introduced in the

1st Session of the 35th Oklahoma Legislature 312

OSMA Distributing Medicare Cut Leaflet . . 317

Two-State Cancer Forum Set For Fort Smith . 317

Congressmen Debate HEW Regulations . . . 319

Medical Assistants’ Seminars Scheduled . . . 320

Hypertension Subject Of Three-Day Seminar . . 322

Patient Referral System Expanded .... 323

Death .......... 323

Tulsa Site For AM A Regional Meeting . . . 324

JCAH Sues HEW Over Survey Documents . . 324

Tulsa County Society Awards Educational Grants 324

Pharmacists’ Convention Adopts Drug Resolutions . 325

Health Service Area Configuration Confirmed . 326

Miscellaneous Advertisements ..... viii

Index To Advertisers ....... xxiv

( Cover Art By William Cason)

iii

500341

One contains aspirin.
One doesn’t.

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100 mg. propoxyphene napsylate
and 650 mg. acetaminophen

Darvon

Compound-65

65 mg. propoxyphene hydrochloride,
227 mg. aspirin, 162 mg. phenacetin,
and 32.4 mg. caffeine

Additional information available to the profession on request.
Eli Lilly and Company, Inc., Indianapolis, Indiana 46206

Oklahoma State Medical Association

editorial

Education of the Coming
Generation of Physicians

(These remarks, made by Ernest Lachman,
MD, on the occasion of his induction into the
Oklahoma Hall of Fame, November 16, 1951,
are as pertinent today as they were more than
twenty-three years ago. Ed.)

The subject, which I have chosen for these
short remarks, pertains to the education of the
coming generation of physicians. Medical edu-
cation is a field with which I have been con-
nected for the last twenty-five years and in
three different countries.

My observations are neither particularly
profound nor probably very original. They can
be summarized in the rather trite statement
that physicians should practice in the conduct
of their own life what they council their pa-
tients to do and that medical school is the place
to indoctrinate students accordingly. Permit
me to elaborate on this.

We know that more than 60 percent of the
ailments which we see in our patients, are con-
nected with the stresses and strains of every-
day life and work. We suggest to our patients a
change of their daily program and a different
philosophy of life. We tell them that they
should have regular periods of relaxation al-
ternating with their work and that they should
take time out for rest and thoughtful re-
flection. We advise them to indulge in hobbies
and widen their fields of interest beyond and
outside the tension producing atmosphere of
their work.

Medical schools all over the country are
going through a phase of optimistic reorgani-
zation, curricula are being revised and physi-
cal facilities enlarged everywhere. American
medical scientific training is leading in the
world today.

Journal / August 1975 / Volume 68

Should we not, during this productive period,
when our thoughts on medical education have
not completely crystalized, incorporate some of
these ideas in our program, so that they may
influence the student during his formative
years?

Should we not provide the external facilities
for physical exercise and relaxation, such as
playgrounds and swimming pools, tennis
courts and gymnasia, libraries and lounges?
More important, should we not encourage our
students to cultivate broader interests, should
we not stimulate their literary and musical in-
clinations and foster an interest in the issues of
today?

The foundation is there: a medical school is
part of a university, and the university is the
place to expose students to a philosophy of life
that allows for happiness and peace of mind
beyond material success.

I need not belabor this point any further, but
I would like to add one more thought, only
loosely connected with the preceding observa-
tions.

If we compare the authorship of articles in
our medical journals today with papers written
thirty or forty years ago, we notice that joint
authorship has become more and more com-
mon. Teamwork in medical research and team-
work in medical practice, as expressed in part-
nerships and frequent consultations among
physicians, are a characteristic feature of
medicine today. It is through the cooperative
endeavor of scientists in different fields, that
medicine advances.

Again we should start with the medical stu-
dent, and encourage team work and joining of
effort in our schools.

If we incorporate some of these thoughts in
our educational program, we will be training a
generation of physicians, fully aware of the
needs of our time. Ernest Lachman, MD

297

president's page

“Regulations or Laws?”

I feel that the most
pressing issue in Okla-
homa medicine today is
Section 224 of Public Law
92-603 that was passed
in 1972. This section of
the law was not imple-
mented until July 1st,

1975. By the time this
page is read by our mem-
bers the law will be in full operation. 1’his law
like many others was implemented at the di-
rection of Secretary Caspar Weinberger. It
provides for a cutback of Medicare and
Medicaid reimbursements. The law provides
for a rollback of the reimbursements to the
amount that was being paid in 1969 and 1970.
The secretary has now ruled that the max-
imum increase in the Medicare and Medicaid
reimbursements will be only 17.9 per cent over
the year of 1969. This represents only three per
cent per year in the last six years. This is a
completely unfair reduction, when we consider
that the cost of living has increased much more
than that.

In announcing the reimbursement rollback
the Secretary of HEW stated that it will save
the federal government approximately $26
million during the fiscal year 1976. What the
secretary failed to point out was that this $26
million will have to be paid out of the pockets
of the Medicare and Medicaid patients.

Our Public Policy Council appears to have,
after many hard weeks of study and work,
come up with a workable solution to the Utili-
zation Review problem. This council has writ-
ten a new type program called "Cost Control
Program for Hospitals.” The program contains
the desirable characteristics such as physician
educational benefits, physician control, no

physician penalty for the physician who is
doing a good job, and no patient penalty; but it
does have a penalty clause for the deviant
physician. It appears at this time that the
Oklahoma plan will be approved as a superior
plan and be implemented in Oklahoma instead
of the Federal Regulations.

It is quiet possible that the Oklahoma plan
will be used as a demonstration project. If this
is actually accomplished, it is possible that we
will receive substantial funding for the ex-
pense of such a demonstration project.

Some of my close friends have been critical of
me and critical of our association for opposing
the Utilization Review regulations of
November 29th, 1974. I have felt that it is my
duty to inform them that the regulations are
not law. Legislation by regulation is one of the
big problems that this country faces. The Con-
gress, too many times, has written into federal
statutes discretionary authority to various sec-
retaries for making rules and regulations to
implement the law. The net effect has been
that non-elected federal employees unilater-
ally write regulations that are not in keeping
with the intent of Congress. Senator Henry
Bellmon feels so strongly about this that he
has introduced legislation requiring reg-
ulations to be submitted to the Congressional
Committee that originated the legislation. It is
absolutely imperative that physicians and
other citizens of this great country express
themselves when their rights are violated by
the federal bureaucracy. It is indeed a danger-
ous situation when a leading segment of soci-
ety sits back and does nothing when reg-
ulations are written that so seriously affect the
sick people of this country. We should all fight
for the rights granted us by the United States
Constitution and the United States Congress.

/<£ ha

298

Oklahoma State Medical Association

Community Genetics I

JAMES G. COLDWELL, MD
BURHAN SAY, MD
KATHRYN JONES, BS

Genetic problems occur with great frequency
in the general population with one out of each
one-hundred newborns having either a
chromosomal defect or a major gene abnor-
mality. A community resource has

been developed.

The purpose of this report is to describe a
portion of a program to provide genetic services
for a community. Cytogenetics have not been
generally available in Tulsa. Equipment was
purchased with Mental Retardation monies,
provided through the Maternal and Child
Health Division of the Oklahoma State De-
partment of Health. The program is located at
Children’s Medical Center (CMC), Tulsa,
Oklahoma, which is a specialized hospital. The
majority of the children have neurological dis-
orders, emotional problems, chronic illness,
mental retardation, or genetic disorders.
Genetic services became fully available in
January, 1974. The services provide chromo-

From the department of Developmental Medicine and Child Neurology,
Children’s Medical Center, Tulsa, Oklahoma 74105

Journal / August 1975 / Volume 68

some studies, dermatoglyphic analysis, and
syndrome identification as well as genetic
counseling. Laboratory facilities available in-
clude a cytogenetic laboratory and a metabolic
laboratory which deals mainly with disorders
of amino-acid metabolism. In the cytogenetic
laboratory, an MD clinical geneticist and two
technicians study patients from CMC as well
as those referrred by outside physicians. The
genetic service is part of the Pediatrics De-
partment.

During 1974, 136 patients, of which 22 were
parents, sibs, etc, were studied for possible
chromosomal aberrations. Table 1 shows a
breakdown of these cases with regard to their
age, sex, and source of referral. Although at
the beginning the majority of the patients were
from CMC, the ratio gradually changed in
favor of those referred by outside physicians.
Most of the 114 probands studied were under
16 years of age and only 10% of the total
number of patients were older than 16 years.
(Table 2) It is interesting to note that the over-
all percentage of abnormalities encountered is
20%, which is about 40 times higher than that

Table 1

Number of Chromosome Studies 136

Patients 114

M— 63
F— 51
CMC— 54
Referrals — 60

Parents, Sibs., etc. 22

299

Genetics / COLDWELL, et al

Table 2, Age Distribution (114 Pts.)

Normal (% 80) Abnormal (% 20)

-12 mos.

-6 yrs.

-16 yrs.

—16 yrs.

92 23

expected in the live-born newborn population.1
This, of course, indicates a careful selection by
the referring physicians before ordering
chromosome studies, still a relatively costly
procedure. Another interesting point in this
respect is the high percentage of abnormalities
(33%) observed among those over 16 years of
age which may be due partly to the fact that
adolescent and adult patients are not usually
referred here for studies unless they have sig-
nificant findings pointing to the possibility of a
chromosomal aberration such as amenorrhea,
short stature, delayed puberty, or abnor-
malities of the external genitalia.

Among the 136 patients on whom cytogenet-
ic studies were carried out, 23 (20%) showed
various abnormalities. As expected, Down’s
syndrome (Trisomy 21) and Turner’s syndrome
(45, XO) were the most common entities.
(Table 3) Although, as seen in Table 4, XYY
karyotype is rather commonly encountered
among the newborns, in our series we did not
have any patients with this chromosomal aber-

James G. Coldwell, MD, graduated from the
University of Oklahoma College of Medicine in
1955. He is a member of the American Academy
of Pediatrics and the American Society of
Human Genetics.

Since his graduation from the School of
Medicine, University of Istanbul in 1946,
Burhan Say, MD, has been certified by the
American Board of Pediatrics. He is a member
of the European Society of Hematology and
Immunology and the European Society of
Teratology.

Mrs. Kathryn Jones, BS received her certifi-
cation in medical technology in 1967 and her
Bachelor of Science in horticulture from Okla-
homa State University in 1974. She is chief
technologist in the cytogenetic laboratory, Chil-
drens Medical Center, Tulsa, Oklahoma.

300

Table 3

Abnormal Karyotypes Encountered (23 pts.)

Trisomy G 7

Mosaic Trisomy G 1

Trisomy D 1

Trisomy C 1

Cri du Chat 1

Extra Metacentric Chr. 1

Translocation (3/15) 2

Turner’s Syndrome 6

Klinefelter’s Syndrome 3

ration. This is probably due to the fact that the
patients with XYY karyotype rarely show eas-
ily recognizable clinical stigmata such as do
those seen in Turner’s syndrome. Although in
the past it was suggested that XYY patients
are quite tall and have somewhat antisocial
behavior, these claims have recently been
strongly disputed by various authorities.2 Fi-
nally, it can also be argued that the rather
small number of patients so far studied may be
the main reason for not observing a case, as
yet, with XYY chromosome constitution.

There were three patients in this series with
interesting karyotypes. One of these involved a
newborn infant who lived only a few days after
birth. He had 46 chromosomes plus a small
metacentric chromosome, the origin of which

Table 4, Chromosome Abnormalities in Newborns1
(31,801 Consecutive Newborns)

Sex Chromosome
Abnormalities

Per 1,000

45, XO 0.15

47, XYY 1.21

47,XXY 1.29

47, XXX 0.89

Others 0.40

Autosome Trisomics

D+ 0.14

E + 0.11

G+ 1.06

Others 0.04

Autosomal Structural
Abnormalities

D/D Translocation 0.72

D/G Translocation 0.22

Other Balanced Translocations 0.75

Unbalanced Translocations and

Deletions 0.25

Pericentric Inversions 0.16

Extra Small Chromosomes 0.22

Others 0.03

TOTAL 5.72

Oklahoma State Medical Association

M XX lU XX

»r> xx

A K X

A Cl f% t\

A A. *• It

’A A X x

A. „

» A A f.

Fig. 1. Karyotype of the patient

could not be established in spite of the use of
newer techniques such as fluorescent and
giemsa banding. Chromosome studies were
also done on the parents, as well as the step-
brother, but with normal findings. It is in-
teresting that in the few such patients which
have been reported in the past, the origin of the
extra chromosome likewise could not be estab-
lished. Clinically, the patient showed many
findings resembling those seen in 18 Trisomy,
which was the clinical diagnosis put forward

by Dr. Martin Greenberg, the referring physi-

cian. A full description

of this patient will be

reported elsewhere.3

:i a n

•

iti

ii [i ai ii

5* n

A# if *

I i * * n » * *4

Fig. 2. A. Karyotype of the patient.

B. Arrows point to the two Y chromo-
somes. (Q banding)

Journal / August 1975 / Volume 68

Another interesting chromosomal aberra-
tion was observed in a family in which two
mentally retarded siblings were found to be
trisomic for a part of the short arm of chromo-
some 3 while the mother had a balanced trans-
location between chromosome 3 and 15. It is
quite likely that partial trisomy for the upper
arm of chromosome 3 may constitute a new
chromosomal syndrome.4 A review of the pre-
viously reported cases with similar
chromosomal aberrations indicates that there
are certain congenital malformations which
are common to most of them involving the car-
diovascular and genitourinary systems. A de-
tailed report for publication is being prepared
and will be published elsewhere.4 Since the
chromosomal aberration seen in the family
provided a unique opportunity for possible as-
signment of genes to the deleted portion of
chromosome 3, skin samples were obtained
from the patients and were sent to Children’s
Medical Center in Boston. It may be mentioned
here that no definite gene assignment has been
made to the number 3 chromosome as yet.

Finally, the last patient with some
cytogenetic interest involved a mentally re-
tarded adult in whom chromosome studies re-
vealed an XXYY karyotype. (Figure 2)

During the past 12 months, many hereditary
conditions were observed in which chromosome
studies were normal. Some of these were well-
described entities. However, there were three
families which were of special interest to us.
One of these was a family, four members of
which had isolated cleft palate in association
with small head size, large ears, and short sta-
ture as cardinal findings. It appears that this
constellation of anomalies represents a
hitherto unreported entity.5

We were able to study another family, four
members of which had double triphalangeal
thumbs in association with brachydactyly,
camptodactyly, subluxation of the patella,
short stature, and borderline intelligence.
After reviewing the literature, we came to the
conclusion that this family also represents a
new dominant (autosomal or x-linked) entity.6

Finally, a four-year-old girl was studied here
with the chief complaint of urinary inconti-
nence associated with partial sacral agenesis.
Further studies indicated that the patient’s
mother as well as one of the female siblings
had similar sacral defects.7 A search of the lit-
erature reveaed that a similar family has been
studied previously by two Danish workers who
proposed an x-linked dominant inheritance for

301

Genetics / COLDWELL, et al

this anomaly.8 It seemed to us that the findings
in the family we studied supported their con-
tention. In view of the fact that there were
multiple stillborn males born to this mother,
we suggested that the gene in question may be
lethal in the hemizygous male. All of these
families are in the process of being reported.

SUMMARY

The utilization of a genetic clinic has been
described. The positive results demonstrate its
need and its value to the community. Other
activities of the program will be described in
subsequent papers. Further development of the
program is planned as resources, primarily fi-
nancial, become available.

REFERENCES

1. Friedrich, U. and Nielsen, J.: Chromosome Studies in 5049 Consecutive
Newborn Children. Clinical Genetics, 4:333, 1973

2. Editorial: What Becomes of the XYY Male? Lancet, 11:1297, 1974

3. Greenberg, M. and Say, B.: A Small Metacentric Chromosome in an Infant
with Multiple Congenital Anomalies. (To be published)

4. Say, B., Barber, N. and Bobrow, M.: Familial 3/15 Translocation with
Partial Trisomy for the Upper Arm of Chromosome 3 in Two Sibs. (To be
published)

5. Say, B., Barber, D. H., Hobbs, J. and Coldwell, J. G.: A New Dominantly
Inherited Syndrome of Cleft Palate. Humangenetik, 1975

6. Say, B. et al.: A New Polydactyly Syndrome. (To be published)

7. Say, B., and Coldwell, J. G.: Hereditary Defect of the Sacrum.
Humangenetik, 1975

8. Cohn, J. and Bay, Nielsen, E.: Hereditary Defect of the Sacrum and Coc-
cyx with Anterior Sacral Meningocele. Acta Paediat. Scand. 58:268, 1969

Children’s Medical Center, P.O. Box 35648, Tulsa,
Oklahoma 74135.

LETTER

Editor

Journal of the Oklahoma State Medical
Association

601 Northwest Expressway
Oklahoma City, Oklahoma 73118

On page 215 of the July, 1975 JOURNAL
(“Yesteryears’ Diagnosis’’), Doctor Ed L.
Calhoon calls attention to the Nannie Doss case
in Tulsa and refers to “a young physician in
Tulsa, Dean Hyde, MD.” The physician referred
to is actually W. Dean Hidy, MD, a Tulsa
surgeon. Doctor Leo Lowbeer, the pathologist at
Hillcrest Hospital, suspected arsenic poisoning
from observations he had made and later con-
firmed this diagnosis to the satisfaction of the
Court.

As Doctor Calhoon implies the Nannie Doss
case was of great import in the 1961 statutes
concerning unexplained deaths.

Walter E. Brown, MD

Tulsa

WEB: daf

IMPORTANT INFORMATION: This is a Sched-
ule V substance by Federal law; diphenoxylate
HCI is chemically related to meperidine. In
case of overdosage or individual hypersensitiv-
ity, reactions similar to those after meperidine
or morphine overdosage may occur; treatment
is similar to that for meperidine or morphine
intoxication (prolonged and careful monitor-
ing). Respiratory depression may recur in spite
of an initial response to Nalllne® (nalorphine
HCI) or may be evidenced as late as 30 hours
after ingestion. LOMOTIL IS NOT AN INNOC-
UOUS DRUG AND DOSAGE RECOMMENDA-
TIONS SHOULD BE STRICTLY ADHERED TO,
ESPECIALLY IN CHILDREN. THIS MEDICA-
TION SHOULD BE KEPT OUT OF REACH OF
CHILDREN.

Indications: Lomotil is effective as adjunctive ther-
apy in the management of diarrhea.

Contraindications: In children less than 2 years, due
to the decreased safety margin in younger age
groups, and in patients who are jaundiced or hyper-
sensitive to diphenoxylate HCI or atropine.

Warnings: Use with caution in young children, be-
cause of variable response, and with extreme cau-
tion in patients with cirrhosis and other advanced
hepatic disease or abnormal liver function tests,
because of possible hepatic coma. Diphenoxylate
HCI may potentiate the action of barbiturates, tran-
quilizers and alcohol. In theory, the concurrent use
with monoamine oxidase inhibitors could precipitate
hypertensive crisis.

Usage in pregnancy: Weigh the potential benefits
against possible risks before using during preg-
nancy, lactation or in women of childbearing age.
Diphenoxylate HCI and atropine are secreted in the
breast milk of nursing mothers.

Precautions: Addiction (dependency) to diphenoxy-
late HCI is theoretically possible at high dosage. Do
not exceed recommended dosages. Administer with
caution to patients receiving addicting drugs or
known to be addiction prone or having a history of
drug abuse. The subtherapeutic amount of atropine is
added to discourage deliberate overdosage; strictly |
observe contraindications, warnings and precautions
for atropine; use with caution in children since signs
of atropinism may occur even with the recommended
dosage.

Adverse reactions: Atropine effects include dryness
of skin and mucous membranes, flushing and urinary
retention. Other side effects with Lomotil include
nausea, sedation, vomiting, swelling of the gums,
abdominal discomfort, respiratory depression, numb-
ness of the extremities, headache, dizziness, depres-
sion, malaise, drowsiness, coma, lethargy, anorexia,
restlessness, euphoria, pruritus, angioneurotic
edema, giant urticaria and paralytic ileus.

Dosage and administration: Lomotil Is contraindi-
cated In children less than 2 years old. Use only
Lomotil liquid for children 2 to 12 years old. For
ages 2 to 5 years, 4 ml. (2 mg.) t.i.d.; 5 to 8 years, 4
ml. (2 mg.) q.i.d.; 8 to 12 years, 4 ml. (2 mg.) 5
times daily; adults, two tablets (5 mg.) t.i.d. to two
tablets (5 mg.) q.i.d. or two regular teaspoonfuls
(10 ml., 5 mg.) q.i.d. Maintenance dosage may be as
low as one fourth of the initial dosage. Make down-
ward dosage adjustment as soon as initial symptoms
are controlled.

Overdosage: Keep the medication out of the reach
of children since accidental overdosage may cause
severe, even fatal, respiratory depression. Signs of
overdosage include flushing, lethargy or coma, hy-
potonic reflexes, nystagmus, pinpoint pupils, tachy-
cardia and respiratory depression which may occur
12 to 30 hours after overdose. Evacuate stomach by
lavage, establish a patent airway and, when neces-
sary, assist respiration mechanically. Use a narcotic
antagonist in severe respiratory depression. Obser-
vation should extend over at least 48 hours.

Dosage forms: Tablets, 2.5 mg. of diphenoxylate
HCI with 0.025 mg. of atropine sulfate. Liquid, 2.5
mg. of diphenoxylate HCI and 0.025 mg. of atropine
sulfate per 5 ml. A plastic dropper calibrated in in-
crements of Vz ml. (total capacity, 2 ml.) accom-
panies each 2-oz. bottle of Lomotil liquid.

Searle & Co.

San Juan, Puerto Rico 00936

Address medical inquiries to:

G. D. Searle & Co.

Medical Department, Box 5110,

Chicago, Illinois 60680 454 R

SEARLE

302 Oklahoma State Medical Association

purpose of drug information
3 patient is to get his coopera-
i followinga drug regimen.

ration and distribution of
it drug information

A/e would hope to amass infor-
nfrom physicians, medical
ies, the pharmaceutical indus-
d centers of medical learning.
Ultimate responsibility for uni-
abeling must, however, rest
ne Food and Drug Administra-
'here is nothing wrong with
?ency saying, "this informa-
generally agreed upon and
ore it should be used,’’ as long
process for getting the infor-
i is sound.

Distribution of the information
oblem. In great measure it
depend on the medication in
on. For example, in the case
njectable long-acting proges-
;, we would think it mandatory
le two separate leaflets— a
me for the patient to read be-
atting the first shot and a long
take home in order to make a
sn about continuing therapy,
case, the information might
directly on the package and
movable at all. But for a medi-
like an antihistamine this
lation might be issued sepa-
thus giving the physician the
of distribution. This could
ve the placebo use, etc.

It is in the distribution of pa-
tient information that the pharma-
cist may get involved. As profession-
als and members of the health-care
team and asa most important source
of drug information to patients,
pharmacists should be responsible
for keeping medical and drug rec-
ords on patients. It is also logical
that they should distribute drug in-
formation to them.

Realistic problems must be
considered

We have to expect that the in-
troduction of an information device
will also create new problems. First,
how can we communicate complex
and sophisticated information to
people of widely divergent socio-
economic and ethnic groups? Sec-
ond, what will we say? And third,
how can we counteract the negative
attitude of many physicians toward
any outside influence or input? Hope-
fully the medical profession will re-
spond by anticipating the problems
and helpingto solve them. Assum-
ing we can also solve the difficulty
of communicating information to di-
verse groups throughout the United
States, our remaining task will be
the inclusion of appropriate material.

What information is appropriate?

In my opinion, technical, chem-
ical and such types of material
should not be included. And there is

no point in the routine listing of side
effects like nausea and vomiting
which seem to apply to practically
all drugs, unless it is common with
the drug. However, serious side ef-
fects should be listed, as should in-
formation about a medication that
is potentially risky for other reasons.

Other pertinent information
might consist of drug interactions,
the need for laboratory follow-up,
and special storage requirements.
What we want to include is informa-
tion that will help increase patient
compliance with the therapy.

Positive aspects of patient drug
information

Labeling medication for the
patient would accomplish a number
of good things: the patient could be
on the lookout for possible serious
side effects; his compliance would
increase through greater under-
standing; the physician would be a
better source of information since
he would be freer to use his time
more effectively; other members of
the health-care team would benefit
through patient understanding and
cooperation; and, finally, the physi-
cian-patient relationship would prob-
ably be enhanced by the greater
understanding on the part of the pa-
tient of what the physician is doing
for him.

le doctor can remove that fear
ir 30 minutes of conversation,
m not suggesting that we
'Id any information from the
t because, first of all, it would
illy dishonest and secondly, it
defeat the very purpose of the
I do think that a patient on the
ontrol pill should knowabout
idence of phlebothrombosis.
you’re going to tell a patient
idence of serious adverse re-
3, then you have to tell him
Concerned medical decision
ade to use a particular medi-
in his situation after careful
eration of the incidence of
cations or side effects.

rnally unstable patients pose
al problem

here are patients who, be-
at severe emotional problems,
aot handle the information
led in a patient package in-
at if we are going to have a
ge insert at all, we just can’t
vo inserts. I think we might
have to tell the families of
)atients to remove the insert
ie package.

triplications of the patient
;e insert

JSt what effect would a pa-

tient package insert have on mal-
practice? We could try to avoid any
legal implications by pointing out
that the physician has selected a
particular medication because, in
his professional judgment, it is the
treatment of choice. For instance,
you can’t tell everyone taking anti-
histamines not to work just because
a few patients develop extreme
drowsiness which can lead to acci-
dents. And what about the very small
incidence of aplastic anemia rarely
associated with chloramphenicol?

If, based on sensitivity studies and
other criteria, we decide to employ
this particular antibiotic, we do so
in full knowledge of this serious po-
tential side effect. It’s not a simple
problem.

How do we handle an insert for medi-
cation used for a placebo effect?

With rare exceptions, physi-
cians no longer use medications for
a placebo effect. This question does
raise the issue of how a patient may
react to receiving a medication
without a pa'ckage insert.

Preparation of the package insert

The development of the insert
ought to be a joint operation be-
tween physicians, the pharmaceuti-
cal i ndustry, the A. M. A. and the F.D. A.

I view the A.M.A.’s role as a co-
ordinator or catalyst. It is the only
organization through which the pro-
fession as a whole, irrespective of
specialty, can speak. It has relatively
instant access to all the medical ex-
pertise in this country. And it can
bring that professional expertise to-
gether to ensure a better package
insert. The A.M.A. can work in con-
junction with the industry that has
produced the product and which is
ultimately going to supply the insert.

I don’t think we should rely, or
expect to rely, on legislative com-
mittees and their nonprofessional
staffs to make these decisions when
it is perfectly within the power of
the two groups to resolve the issues
in the very best American tradition —
without the government forcing us
to do it. I think the F.D. A. has to be
involved, but I’d like them to become
involved because they were asked
to become involved.

Pharmaceutical
Manufacturers Association
11 55 Fifteenth Street, N.W.
Washington, D.C. 20005

Projecting the Estimated Needs for
Internists in Oklahoma Through

the Year 1990

A TASK FORCE REPORT OF
THE OKLAHOMA SOCIETY OF
INTERNAL MEDICINE

Task Force Members
WILLIAM R. SMITH, MD, Chairman
C. S. LEWIS, JR., MD
WILLIAM S. HARRISON, MD
JAMES F. HAMMARSTEN, MD
FLOYD MILLER, MD
TED CLEMENS, JR., MD
JOHN ALEXANDER, MD
GEORGE R. SMITH, MD
THOMAS N, LYNN, MD

The Department of Internal Medicine, Uni-
versity of Oklahoma School of Medicine re-
quested that the Oklahoma Society of Internal
Medicine attempt to ascertain the need for the
services of Internal Medicine specialists over
the next twenty-year period, in order that some
attempt could be made to satisfy these needs
through training programs offered at the
school. The Task Force which was created felt
that consideration should be given to the abso-

308

lute number of Internists available to the state
consumer; the specific types of sub-specialty
personnel available, and the distribution of
these Internists in the various geographic
areas of Oklahoma.

The data for these projections were obtained
from pertinent medical literature, a survey of
practicing Internists in Oklahoma, and popu-
lation projections obtained from the Research
Department of the Employment and Securities
Commission of the State of Oklahoma.

The Task Force is well aware of the difficul-
ties in arriving at such projections. The data
presented must be viewed as preliminary, and
based upon the best available methods of es-
timating these future demands. In reviewing
the current medical literature, we were im-
pressed with the number of articles expressing
opinions about the need for physician
specialists. However, there is a shortage of
hard data available that is of assistance in ar-
riving at accurate estimates.

To initiate this prediction, we felt we must
know the present role of Internists in providing
medical services to Oklahomans: In 1970,
there were 2,528 actively practicing physicians
in Oklahoma, of which 350 identified them-
selves, for American Medical Association rec-
ords, as being engaged primarily in the prac-
tice of Internal Medicine. Thus, in the year

Oklahoma State Medical Association

1970, there was one internist per 7,312 people
in Oklahoma. In order to ascertain the age, lo-
cation and type practice these Internists were
engaged in, we distributed a questionnaire. We
obtained 240 completed questionnaires upon
which we base our data.

As far as age is concerned, there are 86 In-
ternists in the 30-39 year age group; 62 in the
40-49 year age group; 64 in the 50-59 year age
group; 18 in the 60-69 year age group and two
physicians over the age of 70. Age distribution
is essentially the same in urban and non-urban
areas.

Of the 240 physicians responding, we found
that 170 practiced in the urban areas, or in
cities of 100,000 population and above (mean-
ing, Oklahoma City and Tulsa). We found that
100 physicians feel that 60% or more of their
practice consisted of sub-specialty endeavors.
Thus, 42% of the Internists in Oklahoma prac-
tice primarily sub-specialty medicine. On the
other hand, if we analyze the sub-specialty
practices as to community size, we find that 84
of the 100 physicians who practice sub-
specialty medicine, do so in urban areas of
greater than 100,000 population. One hundred
seventy-six Internists felt that their practice
was "primary care” oriented, which comprised
75% of the Internists completing the question-
naire. We made no effort to define the term
"primary care” in the questionnaire.

The summary of the data then would indi-
cate that Oklahoma has one Internist for every
7,312 persons: that 71% of the Internists prac-
tice in urban areas which comprise only 25% of
the State’s population; that a significant
number (42%) of these Internists do primarily
sub-specialty practice (these are also predo-
minantly in the urban areas), and that almost
three-fourths (72%) of the Internists consider
their practices "primary care” oriented.

The optimal ratio of internists per popula-
tion is not well established. However, at the
present time, there are several estimates based
upon programs that seem to satisfy the
consumer’s demand for Internists’ services. For
example, the Baltimore urban area is felt to be
well-supplied with medical services and the
present demand for physicians’ services seems
to be met in this area about as well as any-
where in the United States. The number of In-
ternists per population ratio is one per 4,338
persons. When this is broken down into types
of practice the "primary care” Internists ratio
is 1:5,260. In the Internal Medicine sub-

specialties, the ratio is approximately

1:22,000.

A survey was recently published comparing
the prepaid medical service groups over the
country and the categories of physician
specialists. Analyzing these data it would seem
that the optimal Internist per subscribing
member ratio is one per 4,000 members. (It
must be pointed out that these ratios apply to
demands as they existed in 1970. With the ad-
vent of social change in the method of pur-
chasing health services, as well as the ad-
vancing sophistication of medical services pro-
vided, and the education of the consuming pub-
lic, these demands will increase at an unpre-
dictable rate).

If we apply the ratio of one Internist per

4.000 population as being optimal, at the pres-
ent time, Oklahoma should have 648 practic-
ing Internists. We have 350, leaving a deficit of
298 needed to achieve this optimal ratio. Pro-
jected population estimates for Oklahoma in
1990 are 3,089,400, which is a net gain of

430.000 population. It would take another 107
Internists to fill the need of this increased
population. If thse deficits are to be made up
over a twenty-year period, it would require 21
new internists per year over the normal attri-
tion rate. If we use the normal attrition rate
(death and retirement) Oklahoma will lose 20
Internal Medicine Specialists per year. There-
fore, a total of 41 Internists should be trained
each year over the next 20 years to provide the
optimum ratio of one Internal Medicine
Specialist per 4,000 population. As noted pre-
viously, this does not take into account any in-
crease in demand for Internists’ services over
what appears to be optimal in 1970.

Attempting to arrive at a conclusion as to
how many and what type sub-specialists in In-
ternal Medicine should be available for Okla-
homa is even more difficult. The only data that
we would have to base an opinion on would be
the Baltimore Urban-area study which consid-
ered a ratio of one sub-specialist to 22,000
population as ideal. Using this figure, we
would project that, in the year 1980, we should
have 127 sub-specialists in Oklahoma and by
1990 we should have 140. These projections,
however, are based upon data already ten-
years-old and with the continuing sophistica-
tion of medical technics, we are sure that they
are quite inadequate. Certainly the training
programs in sub-specialty fields should not be
curtailed at this time because the need for gen-
eral Internists seems to be the greatest prior-

Journal / August 1975 / Volume 68

309

Internists / SMITH, et al

ity. The distribution of the various sub-special-
ties in Oklahoma, at the present time, consists
of 43% in cardiology, 9% in chest disease, 7% in
allergy, 7% in oncology, 7% in gastrointestinal
diseases and 27% in other sub-specialties.
Whether this represents an optimal distribu-
tion among these sub-specialties cannot be de-
termined by this survey, and we could find no
reasonable estimate as to an optimal ratio.

As has been pointed out, 42% of the physi-
cians practicing Internal Medicine in Okla-
homa, at this time, are in sub-specialties and
the optimal ratio would appear to be closer to
twenty-five per cent. Serious consideration
should be given to encouraging and designing
training programs that provide a broad-based
knowledge of adult medical practice. The pres-

ent sub-specialty program should not be cur-
tailed, however, the young internists should be
equipped for a primary non-referral-type medi-
cal care practice which appears to be the most
pressing need in our State at this time. Also
attempts should be continued to correct the ap-
parent mal-distribution of Internists’ services
to various population groups in Oklahoma. The
Department of Medicine at the Oklahoma
Health Sciences Center is actively engaged in
exploring methods of correcting this mal-
distribution at the present time.

REFERENCES

1. Assessing the Balance of Physician Manpower in a Metropolitan Area,
"Public Health Reports,” Vol. 85, No. 11, p. 1001.

2. Manpower and Needs by Specialty, "JAMA” Vol. 219, No. 12, p 1621.

3. Numbers of Physicians Required for Primary Medical Care. "New En-
gland Journal of Medicine.” Vol. 286, No. 11, p. 571.

4. Population Estimates for Oklahoma, Personnel Communications Re-
search Department, Employment Securities Commission, State of Oklahoma,
and "Penalogical Survey,” 1972, Oklahoma Society of Internal Medicine.

601 N.W, Expressway, Oklahoma City, Oklahoma 73118

for Medical Assistants

Registration is $15 per program for members
and $18 for non-members or $75 for the entire
series for members and $90 for non-members.
Reservations should be directed to Education
and Certification Committees, AAMA, Inc.,
State of Oklahoma, Inc., 4200 West Memorial
Road, Oklahoma City, Oklahoma 73120.

PROGRAM

September7 6 th:

Expectations of the Physi-
cian

Emergencies

Injections and Medications

Telephone Techniques
Telephone Problems

January 17th:

Preparing the Standard Op-
erating Procedure Manual

October 18th:

Written Communications
Bookkeeping
Indexing and Filing
Mailing Services

February 21st:

Laboratory Procedures
Immunology
Physiotherapy
X-Ray

December 6th:

Examining Room Tech-
niques
Sterilization
Care of Equipment

April 10th:

Medical Ethics
Law and Economics
Medical Records
Credit and Collections

Continuing Education

The Oklahoma Chapter of the American
Association of Medical Assistants, Inc., State of
Oklahoma, Inc., in conjunction with the De-
partment of Continuing Education at Okla-
homa University, is sponsoring a series of six
seminars for medical assistants.

310

Oklahoma State Medical Association

The Venereal Disease
Program Representative

Many venereal disease cases in Oklahoma
are treated by private physicians, and report-
ing of private cases is becoming more complete.
More accurate disease trend information facili-
tates better targeting of limited program re-
sources. Identification and treatment of sexual
contacts of known cases is one key to controll-
ing venereal disease. Most physicians do not
have time to do a thorough epidemiologic in-
vestigation of each venereal disease case they
treat.

When a new case is reported, the report-
ing facility is contacted to obtain additional
information which will assist the investigator.
No individual known to be under private care
is ever contacted without the express permis-
sion of the private physician involved.

The program representative is specially
trained to interview for names and locating
information for all critical-period sexual part-
ners. He describes the health department’s
function and discusses modes of transmis-
sion, incubation period, symptomatic/asym-
tomatic infections, and possible consequences
of untreated infection.

News From
The Oklahoma State
Department of
Health

The investigator confidentially contacts each
person named. The identity of the original pa-
tient is protected. If a contact elects to be seen
by his or her private physician, their doctor is
alerted and epidemiologic treatment is sug-
gested if this preventive procedure is indicated.

Services from program representatives are
available in every county in the state. This in-
cludes darkfield examinations, which can be
performed in the private physician’s office on
relatively short notice.

If you have a specific problem, need to know
how to obtain services, or simply want to meet
your representative, please contact the Ven-
ereal Disease Control Program at the Okla-
homa State Department of Health. The "tradi-
tional” venereal diseases can be controlled as
we work toward the eventual erradication of
all sexually transmitted diseases. □

COMMUNICABLE DISEASES IN OKLAHOMA FOR JUNE, 1975

DISEASE

JUNE

1975

JUNE

1974

MAY

1975

Total To Date
1975 1974

Amebiasis

Brucellosis

—

Chickenpox

213

924

789

Encephalitis, Infectious

Gonorrhea (Use Form ODH-228)

1112

904

940

6121

5227

Hepatitis, A, B, Unspecified

441

565

Leptospirosis

—

Malaria

—

Meningococcal Infections

—

Meningitis, Aseptic

Mumps

149

350

Rabies in Animals

Rheumatic Fever

—

Rocky Mountain Spotted Fever

Rubella

Rubella, Congenital Syndrome

—

Rubeola

116

Salmonellosis

119

Shigellosis
Syphilis, Infectious

167

(Use Form ODH-228)

Tetanus

—

Tuberculosis, New Active

174

153

Tularemia

Typhoid Fever

—

Whooping Cough

For Consultation Call: (405) 271-4060

Journal / August 1975 / Volume 68

311

A Summary of Medical Legislation
Introduced in the 1st Session of the
35th Oklahoma Legislature

INTRODUCTION

Oklahoma lawmakers were two days short of
the Constitutional limit when they adjourned
on June 6th. Eighty-eight legislative working
days produced almost four hundred new laws.
Eleven hundred and seventy seven proposals
were introduced. Medical and medical-related
bills accounted for roughly ten per cent of the
total. Medical education, rural health prob-
lems and medical-legal issues received the
most attention. Seven hundred twenty six bills
will be carried over into the Second Session of
the Thirty-fifth Oklahoma Legislature. Fol-
lowing is a summary of the most important
laws enacted and a review of those bills to be
considered next session.

Internship and Residency Bill. Probably the
most significant new medical law is HB 1552
which allocates funds for internship and resi-
dency programs. The act creates a seven
member Physician Manpower Training Com-
mission, to be appointed by the Governor, six of
whom must be physicians. In addition, there
are eight ex-officio members who serve in an
advisory capacity. They are to represent the
colleges of medicine and osteopathy, the medi-
cal, osteopathic and hospital associations, the
Health Planning Commission and University
Hospital’s Board of Trustees. The commission
total is fifteen.

The primary purpose of the legislation is
to encourage the development of medical edu-
cation programs outside Oklahoma City and
Tulsa.

The commission is charged with the respon-
sibility of reviewing data to establish the need
for additional health manpower by location
and by specialty. They will assist hospitals and

312

communities in organizing programs that can
be accredited. The emphasis is to be on the
primary care specialties defined as internal
medicine, obstetrics and gynecology, pedi-
atrics, emergency trauma and family practice.
The commission will determine the amount a
hospital may be paid for conducting an ap-
proved program, but it shall not exceed $6,000
per student.

The new law also permits a community to
enter into a contract with the commission for
financing a resident’s training. A practice
agreement would be part of the contract.

Initial funding of the new program is
$264,000, however the legislature was pre-
sented budget projections indicating the pro-
gram could cost up to three million by 1980. A
portion of the money must be spent on rural
programs — in FY 1975 5% — but by 1980 40%
of the money must be spent in rural areas.

Prescription Drug Program. Oklahoma’s
Department of Public Welfare could spend up
to nine million dollars during the next year for
prescription drugs. A vendor drug program au-
thorized by the legislature allocates three mil-
lion in state funds to initiate a plan to assist
welfare recipients with ". . . painful or life en-
dangering diseases.” Anticipated federal
matching monies will be six million dollars.

Physicians were officially notified of the pro-
gram in mid-June by Lloyd Rader, Director of
the Department of Institutions, Social and Re-
habilitative Services. Recipients are limited to
three prescriptions per month in designated
categories. Properly prescribed, the depart-
ment will pay for antibiotics, antibacterials,
antineoplastics, analgesics and a broad range
of cardiovascular drugs. In addition, insulin

Oklahoma State Medical Association

and birth control pills are covered. The letter to
physicians explaining the program encourages
generic prescriptions . . consistent with
quality standards,” but permits trade name
prescribing if the physician prefers.

Those eligible for the program will receive a
card from DISRS each month entitling them to
three prescriptions which can be for 100 dosage
units or a 34-day supply, whichever is greater.
Prescriptions written by licensed physicians,
dentists and podiatrists will be honored.

Members of the Oklahoma Pharmaceutical
Association have received a formulary pre-
pared by their association. While not official,
Tate Taylor, Executive Director, feels most
drugs covered by the program have been listed.

Health Maintenance Organizations. A fed-
eral law passed in 1973 authorized funding for
Health Maintenance Organizations but
Oklahoma’s insurance code has effectively
stopped efforts to start such operations in the
state. Two studies — one in Tulsa and another
in Okemah, while not endorsing the HMO con-
cept, did point up the need for special enabling
legislation. Senate Bill 243 authorizes the
Health Planning Commission to issue a license
to an organization that meets the fiscal and
fiduciary tests of the State Insurance Commis-
sion. Another act requires the HMO to justify
the need for its existence to the Health Plan-
ning Commission. Rules and regulations gov-
erning the operations of the HMO are to be
promulgated by the Health Planning Commis-
sion who are ". . . to protect the public, insure
the sound, proper and efficient operation of
health maintenance organizations in this
state.” Strict advertising restrictions are set
forth to prohibit deceptive or untruthful
statements. While enrollment procedures are
not specified in the bill, cancellation of cover-
age is prohibited except for failure to pay.

The Oklahoma Health Planning Commis-
sion is currently composed of R. LeRoy Car-
penter, MD, Commissioner of Health, Hayden
Donahue, MD, Director of Mental Health, and
Lloyd Rader, Director, Department of Institu-
tions, Social and Rehabilitative Services.

Minor Consent Law. After years of debate
about the capacity of a minor to consent for
medical treatment, the Oklahoma Legislature
has passed an omnibus bill granting broad
rights to minors and physicians. House Bill
1537 states that the following minors may con-
sent to have services provided by health pro-
fessionals:

"Any minor who is or has been married, has
Journal / August 1975 / Volume 68

had a child, graduated from high school or is
emancipated; any minor who is separated or
alienated from his parents, or legal guardian
for whatever reason or is supporting himself;
any minor who is pregnant, affected with any
reportable communicable disease, drug and
substance abuse or abusive use of alcohol; any
minor as to his child; any minor who by rea-
son of physical or mental incapacity cannot
give consent and has no known relatives or
legal guardian, if two physicians agree on the
health services to be given; or any minor may
receive non-emergency services for conditions
which will endanger his health or life if delay
would result by obtaining consent from his
spouse’s parent or legal guardian.”

Health services are defined to include ex-
amination, preventative and curative treat-
ment, surgical, hospitalization, and psycholog-
ical services, except abortion or sterilization.

Notification of parents, guardians or spouse
is left to the judgment of the person delivering
the care, as specified in the bill ". . . the
health professional may, but shall not be re-
quired to inform . . . 'and’ . . . the judgment
of the health professional as to notification
shall be final. . . .” No civil or criminal acts
can result from disclosure or the lack of dis-
closure except for negligence or intentional
harm.

Parents, guardians and spouses are exoner-
ated from liability for the payment for services
unless they agree to pay.

Emergency care in a life threatening situa-
tion requires the concurrence of another physi-
cian, if one is available, or a parent, spouse or
guardian if the minor is unable to consent.

For the purposes of the Act, Health Profes-
sional is defined as ". . . any physician,
psychologist, dentist, osteopathic physician,
registered or licensed practical nurse, physi-
cian associate or counselor employed by an
agency licensed under the Oklahoma Child
Care Facilities Licensing Act.

Peer Review Immunity. Physicians serving
on peer review committees are granted im-
munity from liability for damages that may
arise as a result of any actions the committee
takes. The law — House Bill 1277, requires
that the committee be affiliated with the
American Dental Association or the American
Medical Association. Subjects for review are
". . . complaints concerning services, fee,
payments or utilization . . .” Committee

313

news

members must act without malice and in the
best interest of the public.

Certificate of Need. New institutional health
services will require approval of the Oklahoma
Health Planning Commission. Senate Bill 278
declares that it shall be the policy of the State
that development of new institutional health
services should be made in an orderly and eco-
nomical manner consistent with the needs of
various areas of the state. To implement the
policy the Legislature has vested in the Health
Planning Commission the right to issue ''cer-
tificates of need.” Services that require the ad-
vance approval are primarily those that are
provided through hospitals. However, the lan-
guage of the law extends to ". . . other health
care facilities and health maintenance organi-
zations and entities through which such ser-
vices are provided . . .” Nursing homes and
physicians’ offices are not covered by the Act.

Criteria for determining need is to include
". . . the adequacy of institutional services in
the locality, the availability of services which
may serve as alternatives or substitutes, the
adequacy of financial resources for the new
services and the availability of sufficient man-
power to properly staff and operate the pro-
posed new services . . .” Violation of the law is
a misdemeanor.

Death Definition Revised. A law revising the
definition of death establishes brain function
as the basic criteria. The statutes prior to the
new law were vague and left physicians subject
to legal challenge about the time of death.
Some physicians and institutions involved in
transplant operations felt uncomfortable about
their liability under the old act. A dead body is
now defined as ”... a human body in which
there is irreversible total cessation of brain
function; and if, based upon ordinary standards
of medical practice, during reasonable at-
tempts to either maintain or restore spontane-
ous circulation or respiratory function in the
absence of aforesaid brain function, it appears
that further attempts at resuscitation or sup-
portive maintenance will not succeed, death
will have occurred at the time these conditions
first coincide. Death is to be pronounced before
artificial means of supporting respiratory and
circulatory function are terminated and before
any vital organ is removed for purposes of
transplantation.”

Impaired Drivers. Physicians are now im-
mune from civil liability when they report

314

physically or mentally impaired drivers to the
Department of Public Safety.

Traditionally, the medical profession has
vigorously opposed legislation that interfered
with the confidentiality of medical records or
violated physician-patient relationships. How-
ever, Senate Bill 296 received the support of
the medical association. Proponents of the bill
felt that more impaired drivers would be re-
ported if immunity was granted — opponents
felt that the same people, afraid of being re-
ported, would forego needed medical attention.
On the first vote, the House rejected the bill
48-46. Three days later the vote was over-
turned and the bill passed 66-28. Essentially,
the law provides that a physician may make a
written report on the ability of a patient (when
he is treating or has treated) to operate a motor
vehicle. The report, nor action resulting from
the report can be the cause of action against
the physician. The law further provides that
the department may, in its discretion, suspend
or cancel the license for a period it considers
justifiable.

Rural Loan and Scholarships. Several
amendments were made to Oklahoma Rural
Loan and Scholarship Program. Started six
years ago, the fund has financed the medical
education of a number of physicians who
agreed, as a condition of participation to prac-
tice medicine in rural areas of the state. One
year of service is required for each year of fund-
ing. No repayment is required if the service
commitment is honored. Under the original
law, the population ceiling was 5,000. The
amendment raised the limit to 7,500. Max-
imum loan amounts have also been raised from
$5,000 to $7,500. The Legislature has appro-
priated $100,000 to the fund each year for sev-
eral years but at Governor Boren’s request,
raised funding to $200,000 for fiscal year
1975-76.

The most significant change in the law has
been the governing board. The original law es-
tablished a Rural Loan and Scholarship Board.
Authority to operate the program has now
been transferred to the new Physician Man-
power Training Commission.

Insurance Coverage for Newborn. Health in-
surance benefits for a newly born child are
guaranteed if the family has health insurance
coverage. Some insurance policies did not cover
newborn until certain periods of time elapsed
— two, three days, etc. Now, however, com-
panies writing insurance in Oklahoma must
cover the child from the time of birth. The new

Oklahoma State Medical Association

law, modeled after a uniform proposal written
by the American Academy of Pediatrics, was
supported by the Association.

Disabled Granted Treatment Rights. Per-
sons with infirmities or disabling illnesses that
wear identifying symbols are entitled to spe-
cial treatment. A disabled persons Act sets
forth the manner in which law enforcement of-
ficers are to treat persons . . unconscious,
semiconscious; incoherent or otherwise in-
capacitated to communicate . . .” provided
they are wearing the American Medical As-
sociation emergency symbol. The procedure
requires that the officer make a diligent search
for the identifying medal and identification
card. If found, every effort is made to find the
personal physician of the victim — failing, the
officer transports the person to the hospital.

Objective of the law is to reduce the incar-
ceration of the sick people. Several incidents
have occurred when victims of epileptic seiz-
ure, diabetic coma and cardiac blackouts have
been booked in jail with little or no effort to
ascertain if the person was ill. The new law not
only mandates the method of handling but also
protects those that attempt to help the victim.

No Smoking. "Lighted tobacco in any form is
a public nuisance and dangerous to public
health . . .” so states the smoking ban pro-
posed by the Oklahoma Lung Association.
Legislators felt smoking was hazardous to your
health but only in elevators, indoor theaters,
libraries, art galleries, museums, concert halls
and buses, and then only if "No Smoking” signs
were posted. Final passage of the measure also
permits smoking in adjacent rooms and sepa-
rated areas if "Smoking Permitted” signs are
posted.

Acupuncture. Limiting acupuncture to
licensed physicians was attempted in Senator
Frank Keathing’s Senate Bill 398. Strong op-
position from chiropractors resulted in the bill

being held over until next session. The bill,
while very simple, is sure to create con-
troversy. Rules and regulations governing the
practice of acupuncture would be promulgated
by the Commissioner of Health.

Medical Malpractice. The association spon-
sored five bills that are designed to reduce the
number of claims filed and enhance the associa-
tion attorneys’ ability to defend personal injury
actions. All will be considered next session.
One proposal will permit a physician to file a
counterclaim against his plaintiff and have the
suit tried at the same time the action brought
by the plaintiff is tried. Another of the five
measures prohibits an action for breach of war-
ranty unless the warranty is in writing. Reduc-
ing the time period for filing a claim is the
objective of Senate Bill 450. The present sta-
tute of limitations would be reduced to one
year from ". . . the date the claimant knew or
should have known . . . and in no event . . .
more than four years after the date of
occurrence. . .” The other two measures pro-
vide for the admissibility of collateral sources
and the manner in which the jury can be in-
structed. It is anticipated that medical mal-
practice will be a major subject during the sec-
ond session of the 35th Legislature.

Workmen’s Compensation. The disability in-
surance program for most Oklahoma’s work
force will undergo scrutiny this summer by a
special Gubernatorial Study Committee. High
rates, low benefits and fear of federalization
precipitated the examination. Long criticized
by labor, business and medicine, the program
is overdue for revision. The association has ad-
vocated changes for years. A medical panel to
review reports was offered during the Bartlett
years. Resistance from Industrial Court Judges
resulted in elimination of the panel. Hopefully,
the new study will result in positive legislative
action. □

NEW MEDICAL OFFICES FOR LEASE

34’ x 52’, Ground Level, Plan to Suit

5320 North Portland

(Across From Deaconess Hospital)

Contact Bryce Petrie, MD 942-0600

Journal / August 1975 / Volume 68

315

Take advantage si the off season rate.

Combine your education & your vacation.

Southern Medical Association

finual

cientific Meeting

Miami Beach, Florida - Hotel Fontainebleau

We could draw pretty word pictures
about Miami— the scintillating beaches, the
glamorous hotels, the superb cuisine, the
intriguing spots to visit, the unequaled
vacationland— but we won’t. You’ll have to
find out for yourself.

But we will tell you about the most ex-
citing scientific medical meeting of the year
- the 69th Annual Scientific Meeting of the
Southern Medical Association - featuring
a wide range of symposia, 22 sections, live
teaching demonstrations, learning center,

316

9. 1 975

postgraduate courses, closed-circuit televi-
sion-something for every specialty.

The Continuing Education Program of
the Southern Medical Association has been
granted full approval by the American
Medical Association’s Council of Medical
Education.

The best of two worlds is awaiting you.

Make your plans now while reservations
are available. Write: Southern Medical
Association, 2601 Highland Avenue, Bir-
mingham, Alabama 35205.

Oklahoma State Medical Association

OSMA Distributing
Medicare Cut Leaflet

A leaflet, designed to be sent out as a
"statement stuffer,” is being distributed by the
OSMA to all of its members. The leaflet ex-
plains the reduction in Medicare benefits now
being seen by Medicare beneficiaries.

In 1972, the United States Congress enacted
Public Law 92-603. A portion of that law in-
structed the Secretary of Health, Education
and Welfare to roll back Medicare payments
toward doctor bills to the amounts physicians
were charging in 1969 and 1970, plus a small
yearly increase to be set by the Secretary. The
law was not enforced until this year, when the
Secretary issued implementing regulations.

The leaflet is designed to show Medicare re-
cipients why the phrase "more than the allow-
able charge” is beginning to appear more and
more often on their Medicare benefit explana-
tion form. The leaflet reads as follows:

TO MY MEDICARE PATIENTS
YOUR MEDICARE BENEFITS ARE
BEING CUT

Your Medicare reimbursement is now being
cut drastically! This reduction in Medicare
benefits was brought about by the recent appli-
cation of a 1972 federal law.

Public Law 92-603 instructed the Secretary
of Health, Education and Welfare to roll back
Medicare payments toward doctor bills to the
amounts physicians were charging in 1969 and
1970, plus a small yearly increase to be set by
the Secretary.

The Secretary has now ruled that the max-
imum increase in the Medicare reimbursement
for physicians’ fees will be only 17.9% over
1970 levels. This unfair reduction in your Med-
icare benefits is made all the more obvious
when you consider that in the same time period
the cost of living has increased more than 43%,
housing costs have gone up more than 46%, the
cost of transportation has increased 34% and
food has increased 57% !

Because of this benefit reduction you will
begin to see the phrase "more than the allow-
able charge” appear more often on your Medi-
care benefit explanation form. Please under-
stand that the "allowable charge” referred to is
the reduced amount that Medicare has decided
it will pay for your medical care.

In announcing the reimbursement rollback
the Secretary of HEW stated that it will save
the federal government approximately $26

million in 1976. What he failed to point out
was that this $26 million will have to be paid
out of the pockets of persons on Medicare, the
very persons that the program was designed to
help.

The Secretary apparently ignored the fact
that the Medicare eligible population of this
country, those 65 years of age or over, are the
ones traditionally living on a limited or fixed
income.

If you are concerned, write your Congress-
man, U.S. Senators and the President of the
United States in care of Washington, DC, to
protect your interests.

One hundred copies of the leaflet were sent
to every physician member of the OSMA for
distribution to his Medicare patients. The pro-
duction and distribution of the leaflet was
made possible by the $100 voluntary contri-
bution made to the association by many of its
members.

At the same time physicians were receiving
copies of the leaflet for distribution, a news ar-
ticle went to every newspaper, radio and TV
station in the state explaining the leaflet and
its function. □

Two-State Cancer Forum
Set For Fort Smith

Fort Smith, Arkansas will host the annual
Kansas-Oklahoma Cancer Forum September
25th-26th. This year’s program was developed
in cooperation with the Memorial Hospital and
Sloan-Kettering Institute of New York City.

The day and a half program concentrates on
discussions dealing with the practical
management of various types of cancer. The
first presentation will begin at 8:30 the morn-
ing of September 25th in Fort Smith’s Shera-
ton Inn.

Specialists in the field of pathology, colon sur-
gery, breast surgery, gynecologic surgery, ra-
dial therapy, chemotherapy and immuno-
therapy will discuss recent advances in cancer
management. The program also stresses early
detection of breast cancer, psychiatric support
of the cancer patient and rehabilitation of the
patient.

Room reservations for the two days should be
made directly with the Sheraton Inn, Fort
Smith, Arkansas 72901. There is no registra-
tion fee for the program. All members of the
medical profession, registered nurses and med-
ical students are invited to attend. □

Journal / August 1975 / Volume 68

317

BEVERLY HILLS HOSPITAL
BE VEIL Y HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

PSYCHIATRY

Jackson H. Speegle, MD
John T. Holbrook, MD

PSYCHOLOGY

George R. Mount, PhD
Donald L. Whaley, PhD

Tom I. Payton, MS
Patrick R. Barnes, MS

EDUCATION DIRECTOR

William E. Nix, PhD

Fred H. Jordan, MD
Joseph H. Lindsay, MD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND R.T. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

318 Oklahoma State Medical Association

Congressmen Debate
HEW Regulations

A proliferation of unpopular regulations by
the Department of Health, Education and Wel-
fare resulted in an unusual one-day "public
oversight” hearing by the House, Ways and
Means Committee of the United States Con-
gress. Purpose of the meeting was to determine
if the Department of HEW had superseded
congressional intent in an increasing number
of Medicare costs-control regulations.

The subcommittee hearings, chaired by Dan
Rostenkowski (D-Illinois) resulted in angry
confrontations between the HEW Secretary
and health care providers. However, un-
daunted by a solid array of heated opposition
for medical hospital groups, Secretary Caspar
Wienberger told the subcommittee that the
four disputed Medicare regulations will save
about $250 million a year and "improve the
quality of care.”

Rostenkowski stated, "I hope the subcom-
mittee can remove roadblocks. We should
really try to get the government and the health
care industry out of the courtroom and into the
conference room where the debate belongs.”
His reference to the courtroom dealt with four
lawsuits having been filed against the HEW
Department to overturn the regulations.

The American Medical Association, along
with other hospital and physician groups,
urged the lawmakers at the hearing to crack
down on HEW for going beyond the intent of
law. At the same time Weinberger refused to
acknowledge any merit in the private sector’s
attacks on the regulations and insisted that
they followed the intent of Congress and were
needed to curb costs.

The regulations under fire included the So-
cial Security Utilization Review Plan requir-
ing elaborate institutional post-admission re-
view mechanisms; reducing the schedule of
limits on hospital inpatient general routine
service costs from the 90th to the 80th per-
centile; a limitation on recognition of physi-
cians’ prevailing charge increases, based on an
economic index; and termination of the inpa-
tient routing nursing salary cost differential in
calculating hospital reimbursements.

Stressing a common theme among the wit-
nesses, the AMA cited "a general feeling of
futility concerning administrative action felt
by the public as a whole, but especially by
groups subject to and particularly affected by
federal regulations.” Ernest Livingstone, MD,

Journal / August 1975 / Volume 68

Chairman of the AMA’s Council on Legisla-
tion, said many professional associations dis-
play "an attitude often of exasperation,
consternation and indignation with respect to
the bureaucratic administration of govern-
ment programs.” He went on to point out that
administrative regulations often expand upon
or entirely subvert the intent of Congress. This
is why, he explained, the AMA for the first
time in its long history has recently sued the
HEW Department over the Utilization Review
Regulations.

In reference to the Medicare reimbursement
rollbacks, the AMA pointed out that HEW had
barged ahead on the physicians Medicare fee
index without giving interested parties a
chance to question the details of the regula-
tions. Edgar Beddingfield, MD, Vice-Chairman
of the AMA Council on Legislation, said that
there was no justification in either the law or
its legislative history for imposing a national
economical index. He then went on to note that
Medicare fee recognition "has long lagged be-
hind current trends in physicians’ fees.”

The Medicare fee index limits reimburse-
ment to 17.9% above reimbursement levels
prevailing in fiscal year 1973. The reimburse-
ment level in that year was actually based on
charges being made by physicians in 1969 and
1970. The new payment formula, according to
Secretary Weinberger, will save the govern-
ment an estimated $26 million during this fis-
cal year. However, it has been noted that be-
cause of the fee rollback many physicians will
refuse to accept assignments, and the $26 mil-
lion will have to be made up out of the pockets
of Medicare recipients.

The AMA charged that Congress intended
local, rather than national indexes, when it
wrote the law and that the limitation was not
supposed to be on a procedure by procedure
basis but on an aggregate. They also charged
that HEW allowed insufficient time for discus-
sion on the matter in which it had decided to
draw up the index. The AMA warned that the
control would simply force more and more
physicians to abandon the assignment method.

Other organizations, the American Hospital
Association, in particular, testified regarding
the other regulations.

In a separate action, the Association of
American Medical Colleges has filed suit to
prevent the Department of HEW from imple-
menting Medicare-Medicaid hospital cost con-
trol regulations. The action is seeking a pre-
liminary injunction against regulations which

319

news

set limits on routine service costs and short
term, non-federal hospitals.

AAMC said that the regulations failed to
consider factors in hospital cost measurement
that the Congress wrote into the law; namely,
the scope of services offered, the quality and
intensity of care, and hospitals educational
programs. As a result, many hospitals’ daily
cost will soar far beyond the amounts allowed,
AAMC says.

HEW’s reimbursement schedule for these
routine daily costs groups hospitals according
to their urban or nonurban location, area per-
capita income, and bed number. AAMC Presi-
dent, John A. D, Cooper, MD, said, "if these
new regulations are allowed to stand, Medicare
patients could lose up to $68 million worth of
hospital services next year.” He went on to
point out that Medicaid charges would also be
affected since they are tied directly to those of
Medicare.

"The new ceilings for payments will work a
tremendous hardship on you as hospitals,” the
President said. "More importantly, they will,
for the first time since Medicare began, place
many Medicare patients in jeopardy of having
to pay for a portion of their hospital costs.” □

Medical Assistants’

Seminars Scheduled

A series of seminars for the persons that
work in physicians’ offices have now been
scheduled by the Oklahoma Chapter of the
American Association of Medical Assistants,
Inc., State of Oklahoma, Inc. Working with the
Continuing Education Department of the Uni-
versity of Oklahoma, medical assistants have
set up a series of six day-long programs to be
spread over the next eight months.

Each of the six sessions will focus on a par-
ticular area of a medical assistants responsibil-
ity. It is hoped that the series will assist Okla-
homa physicians with the problem of staff
training.

Each of the sessions will be held in Kellogg
Center on the Oklahoma University Norman
Campus. Registration fee, which includes
course materials and lunch, will be $15 per

320

session for members and $18 for non-members
or a person can pre-register for all six pro-
grams for $75 for members and $90 for non-
members. For members of AAMA, continuing
education units will be awarded to all partici-
pants for attendance in each session.

Each of the six scheduled sessions will start
at 9:00 in the morning and be completed by
about 3:00 in the afternoon. The first will be on
September 6th. The morning program will be
entitled "Expectations of the Physician” and
will feature V. Michael Barkett, MD, Okla-
homa City. The afternoon session will deal
with telephone techniques and oral communi-
cations with representatives from Southwest-
ern Bell Telephone and a panel of medical as-
sistants contributing to the program.

The second session is scheduled for October
18th. The morning portion will be devoted to
written communications, bookkeeping and
indexing in filing. Doctor Laura Blair, Okla-
homa University, will be responsible for the
morning presentation. The afternoon program
will deal with United States mail service, or
"How To Realize Maximum Benefits from the
Public Mail System.”

The third session is scheduled for December
6th and will cover examining room techniques,
sterilization and care of equipment. The after-
noon will be devoted to medical emergencies
and injections and medications.

The first session of the new year is set for
January 17th, 1976. The entire program will
be devoted to study of the Standard Office Pro-
cedure Manual and will include actual exer-
cises in devising a Procedural Manual for each
office represented. A Special Physicians Man-
agement Journal is being prepared for this ses-
sion. The price of the manual will be ap-
proximately $30 and it will be divided into 12
subdivisions.

The session scheduled for February 21st will
deal with laboratory procedures, immunology,
x-ray and physiotherapy.

The last scheduled session will be on April
10th and subjects will include medical ethics,
law and economics, medical records and credit
information and collections.

Persons wishing to attend the meetings
should direct their reservations to Mr. Floyd
Taylor, Education and Certification Commit-
tee, AAMA, Incorporated, State of Oklahoma,
Inc., 4200 W. Memorial Road, Oklahoma City,
Oklahoma 73120. Reservations may also be
made with Mr. Taylor’s office at the Kellogg
Center in Norman. □

Oklahoma State Medical Association

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance
Springfield, Mass.

For additional details and application form, please contact

Jim Thaxton

Administrator

720 N.W. 50th Telephone 405 848-7661

P.O. Box 1 8593 Oklahoma City, Oklahoma 731 1 8

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

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Is this logical? Not when you can participate in the . . .

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For Additional information, call or write

Jim Thaxton, Bill Howard or Rodman A. Frates
C. L. FRATES & COMPANY, INC.

720 N.W. 50th P.O. Box 18695
OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848-7661

Journal / August 1975 / Volume 68

321

news

Hypertension Subject
Of Three-Day Seminar

"A New Look at the Hypertensions” will be
the subject of an October 2nd-4th seminar
being sponsored by the University of Okla-
homa Health Sciences Center and the Ameri-
can College of Physicians.

The program is being directed by Edward D.
Frohlich, MD and is scheduled for the Skirvin
Plaza Hotel. While most courses on hyperten-
sion have been directed toward establishment
of uniform community health programs for the
detection and evaluation of a hypertensive pa-
tient, this three-day program has been de-
signed for the practicing internist and family
physician to update their concepts of the broad
considerations that underlie the multiplicity of
problems that afflict patients with hyper-
tension.

One half-day each will be devoted to the
endocrine, renal and cardiovascular areas with
additional half-days each devoted to under-

standing of the new diagnostic techniques and
therapeutic advances.

Guest faculty for the course includes Nor-
man N. Kaplan, MD, Professor of Internal
Medicine at the University of Texas South-
western Medical School in Dallas; John H.
Laragh, MD, Master Professor of Medicine and
Director of Hypertension Center and Cardio-
vascular Center at the New York Hospital-
Cornell Medical Center; and Morton H. Max-
well, MD, Director of Hypertension Services at
the Cedars-Sinai Medical Center and Clinical
Professor of Medicine at UCLA School of
Medicine.

In addition to the guest faculty, some 21
members of the University of Oklahoma fac-
ulty will serve on the program.

Registration is limited to 150 people max-
imum. Registration fee is $150 for members or
fellows of the American College of Physicians;
$175 for non-members; $60 for ACP associates;
other residents and fellows are $120; and stu-
dents are $50.

Registration and request for information
should be directed to Registrar, American Col-
lege of Physicians, 4200 Pine Street, Philadel-
phia, Pennsylvania 19104. □

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322

Oklahoma State Medical Association

Patient Referral System Expanded

An expanded patient referral system, de-
signed to facilitate referrals from physicians
around the state, is now in operation at The
University Hospital and Clinics.

Announcement of the operation of the ex-
panded referral system was made by Don H.
O’Donoghue, MD, Oklahoma City physician
and Chairman of the hospital’s Board of Trust-
ees. "This broadened program, combined with
the modern private facilities of the Everett
Building and the reopening this month of three
completely remodeled nursing units, provides
us with the elements to respond quickly to
physician referrals from around the state and
to better deliver high quality, comprehensive
health services to patients from all walks of
life,” Doctor O’Donoghue said.

"An important element of the expanded re-
ferral system is a new toll-free telephone line
now available to physicians for their referrals,”
G. Rainey Williams, MD, Associate Chief of
Staff and a member of the Task Force for Im-
plementation of the Referral System, ex-
plained. "This referral number, 1-800-
522-4264, is available to physicians through-
out the state,” Doctor Williams continued. He
also noted that physicians in the Oklahoma
City metropolitan area can call the local num-
ber, 271-4900.

"This new mechanism for referrals is intend-
ed to make it possible for any physician to dis-
cuss medical problems or to refer patients with
a minimum expenditure of time and effort,”
Doctor Williams added.

Another important element of this expanded
referral program is the hospital’s newly ac-
quired emergency vehicle which contains life
support equipment. "This vehicle is designed
as a life-supporting vehicle for facilitating re-
ferral of the critically ill,” Doctor Williams
noted. "It will not compete with any commer-
cial ambulance service,” he emphasized.

"The vehicle will be utilized in three types of
situations calling for life-support equipment,”
Doctor Williams said. These three situations
include (1) transferring critically ill patients
from the MAST helicopter at the Governor’s
Helipad to University Hospital; (2) admission
to University Hospital of critically ill or in-
jured patients who require the use of equip-
ment in this emergency vehicle when no com-
parable vehicle is available and (3) pick-up and
delivery of University Hospital patients who
require specialized services at other metropoli-

tan hospitals which are not available at Uni-
versity Hospital, such as the EMI scanner or
some types of renal dialysis.

The vehicle will be staffed with registered
Emergency Medical Technicians 24 hours a
day plus other nursing and allied health
personnel as indicated by the patient’s condi-
tion and the judgment of the University Hospi-
tal clinical staff member who is accepting the
patient. A basic pick-up charge will be assessed
for use of the vehicle, as well as a mileage
charge outside the metropolitan Oklahoma
City area.

Doctor Williams noted that physicians
across the state will be receiving next month a
newly developed Referral Guide containing
information about each of the hospital’s service
areas, referral and admitting procedures. This
guide also includes information for patients
and visitors, maps of the area and of the hospi-
tal, and written directions on how to reach the
hospital from major highways which the physi-
cians can reproduce and give to their patients
being referred to University Hospital.

"This streamlined referral system, which
was partially funded under a grant from the
Oklahoma Regional Medical Program, is de-
signed to improve procedures for making the
tertiary patient care resources and services of
this hospital more available to all Okla-
homans, prticularly those in underserved rural
areas,” Doctor Williams emphasized. "Much
work and effort has been put into improving
communication procedures and establishing
the referral telephone lines. We hope this is
evidenced in our ability to better meet the
needs of referring physicians.” □

DEATH

RICHARD B. LINCOLN, MD
1919-1975

Richard B. Lincoln, MD, 56, Okla-
homa City psychiatrist and neu-
rologist, died July 10th, 1975. Born in
Muskogee, Oklahoma, Doctor Lincoln
moved to Oklahoma City in 1940. He
was graduated from the University of
Oklahoma College of Medicine in 1946.
Following residency training in Okla-
homa City and Chicago, he established
his practice in Oklahoma City in 1950.

Doctor Lincoln was a member of the
Oklahoma City Clinical Society. □

Journal / August 1975 / Volume 68

323

news

Tulsa Site For
AMA Regional Meeting

Tulsa has been selected as the site for a
two-day AMA Regional Scientific Meeting
next year.

For many years the American Medical
Association has held two large scientific meet-
ings each year, one in the spring and the sec-
ond in the fall. The fall meeting is now being
phased out and replaced by regional scientific
meetings scattered throughout the United
States.

The Tulsa meeting will be held Saturday and
Sunday, January 17th and 18th. The program
for the first day will include "Child in the
Emergency Room” and "Cardiac Arrhyth-
mias.” The Sunday program will include
"Dermatology for the Non-Dermatologist,”
"Management of the Critically Injured, ’ and
"Acid-Base Fluid and Electrolyte Balance.”

Cardiopulmonary resuscitation will be pre-
sented both days.

The AMA’s Department of Scientific Assem-
bly is working with Doctor Ralph Richter,
Director of Continuing Medical Education at
the University of Oklahoma School of Medicine
in Tulsa to plan the two-day program. As soon
as the program is finalized, formal invitations
and schedules will be printed for distribution
to all physicians in this region of the United
States. □

JCAH Sues HEW
Over Survey Documents

The disclosure of survey documents provided
to the Health, Education and Welfare Depart-
ment by the Joint Commission on Accredita-
tion of Hospitals has resulted in a lawsuit. The
suit, filed in US District Court, calls for a per-
manent injunction to prevent further public
disclosure of JCAH survey documents provided
for the purpose of validation surveys conducted
by HEW.

The Joint Commission filed the complaint
May 30th against Caspar Weinberger as Sec-
retary of the Department of Health, Education
and Welfare.

Title XVIII of the Social Security Act pro-
vides that a hospital accredited by JCAH

324

"shall be deemed” in compliance with the con-
ditions of participation for Medicare. In 1972
the law was amended to provide that the state
agencies in agreement with HEW could con-
duct validation surveys of JCAH creditation
findings on a random sample basis. JCAH was
then to provide the Secretary of HEW "on a
confidential basis” and with the hospitals’
permission, its most current survey of those
hospitals selected for the validation survey
process.

On April 24th Secretary Weinberger re-
leased to the Consumer Commission on the Ac-
creditation of Health Services, Inc., of New
York, 105 of the JCAH accreditation letters
and accompanying recommendations and
comments.

In the lawsuit, JCAH maintains that its
standards for accreditation of hospitals repre-
sent "optimal achievable standards” and that
the criticism letters are designed to assist the
hospital achiever optimum standards, not
minimum standards.

At the same time JCAH was filing its law-
suit, it was informing the Secretary that the
organization was immediately discontinuing
the provision of hospital survey reports to the
Bureau of Health Insurance pending a reestab-
lishment of a basis of confidential handling of
data thus supplied. □

Tulsa County Society Awards

Educational Grants

The Scholarship Fund of Tulsa County Med-
ical Society has announced a total of $7,500 in
educational assistance grants to eleven area
medical and nursing students for the 1975-76
school year.

E. N. Lubin, MD, President, said the sum
was a record annual distribution by the non-
profit educational trust established in 1963 by
the doctors’ group.

Winners of the Doctor Anna Luvern Hays
Memorial Scholarships of $700 each are Danny
A. Amrine, Titus D. Duncan, Bruce A.
Kraemer, Michael A. Madden, from Tulsa, and
Teresa M. Shavney, Sand Springs.

Amrine and Duncan are sophomores at the
University of Oklahoma College of Medicine,
and Shavney is a freshman at the same school.
Kraemer is a freshman at Washington Univer-
sity School of Medicine, St. Louis, Missouri,

Oklahoma State Medical Association

and Madden is a sophomore at Georgetown
University School of Medicine, Washington,
D.C. These awards are made possible by a be-
quest from the late Doctor Anna Luvern Hays,
Tulsa pediatrician who died in 1965.

The Doctor Frank L. and Jessie O. Flack
Scholarship of $700 was given to Beverly N.
Balfour, Tulsa, a freshman at the University of
Oklahoma College of Medicine. The award was
created by Mrs. Flack in memory of her hus-
band, Doctor Frank L. Flack, Tulsa surgeon
who died in 1963. It was first given two years
ago.

The second annual award of the Glenda Ann
Cale Memorial Scholarship of $700 again went
to Susan M. O’Brien, Tulsa, a sophomore at the
University of Oklahoma College of Medicine.
This scholarship was established last year in
memory of a 23-year old Southwestern Bell
Telephone Company employee found murdered
in late 1972. It utilizes an unclaimed reward
fund raised by Tulsa physicians and other
friends of Miss Cale.

The Doctor O. C. Armstrong Scholarship of
$700, created by the retired Tulsa physician,
was given to Sharon M. Henthorn, Tulsa, a
senior at the University of Oklahoma College
of Medicine, Tulsa. She is the first student of
the new Tulsa medical college to receive an
award.

The Doctor Goerge H. Miller Memorial
Scholarship was received by Douglas G. Cox,
Tulsa, an O.U. College of Medicine sophomore.
It was made possible by gifts from the family
and friends of the late Doctor George H. Miller,
Tulsa surgeon, who died last January 30. The
amount is $700.

Aletha C. Oglesby, Tulsa, was recipient of
the $700 annual scholarship given by the
Woman’s Auxiliary to Tulsa County Medical
Society. She is a sophomore at the University
of Oklahoma College of Medicine.

Winner of the Doctor Maxwell A. Johnson
Memorial Scholarship of $500 was Gerald H.
Milligan, Tulsa, a senior at Harris College of
Nursing, Tulsa Christian University, Fort
Worth, Texas. The award was created in mem-
ory of the Tulsa urologist and medical leader
who died in 1971.

Amrine, Duncan, O’Brien, Oglesby and
Milligan are previous recipients of awards
from the Scholarship Fund of Tulsa County
Medical Society.

The annual educational assistance program
is designed to stimulate interest in careers in
medicine and allied health sciences. D

Pharmacists’ Convention
Adopts Drug Resolutions

During its June meeting the Oklahoma
Pharmaceutical Association, made up of
pharmacists from throughout the state, adopt-
ed a number of resolutions dealing with pre-
scriptions for drugs.

In one action the pharmacists again restated
their intention to discourage and prevent the
advertising of prescription drugs to the general
public.

Three resolutions of particular importance to
prescribing physicians were adopted. The
resolutions outlined problems that the
pharmacists encounter when a prescription is
not properly prepared. The pharmacists en-
courage all practitioners to indicate on the pre-
scription whether or not it should be refilled,
thus eliminating unnecessary phone calls.

Another problem area is that of prescriber
identification on a hospital prescription blank.
Frequently pharmacists are presented with a
prescription on a hospital blank that does not
have the physician’s name imprinted on it. The
problem is compounded when the prescription
is signed by an intern or resident unknown to
the pharmacist.

The pharmacists also passed a resolution to
remind all physicians that the pharmacists
must file controlled substances prescriptions in
a separate file. A problem is presented when-
ever a physician writes multiple prescriptions
on the same blank and only some of them are
for controlled substances.

Resolutions were adopted by the Oklahoma
Pharmaceutical Association during its annual
meeting June 6th-8th. □

Remember These Dates -

MAY 5th, 6th, 7th, 8th, 1976

Oklahoma Medical Summit ’76

A combined meeting of the Oklahoma
State Medical Association, the Oklahoma
City Clinical Society and the Oklahoma
Academy of Family Physicians.

Journal / August 1975 / Volume 68

325

news

Health Service Area
Configuration Confirmed

Governor David Boren’s decision to des-
ignate the State of Oklahoma as one Health
Service Area has apparently been upheld
amidst speculation he might change his mind.
Newspaper accounts indicated that at the re-
quest of Congressman James Jones, Tulsa, the
Governor may reconsider his decision. Au-
thorities in the Governor’s office have stated
that no change in the plan will be requested
although regional DHEW officials suggested
that the Governor reconsider. State HSA desig-
nations are to be published in the Federal
Register on August 1st finalizing the first step
in implementing the National Health Plan-
ning and Resources Development Act of 1974.

The comprehensive law has as its primary
objective the planning, development and
implementation of a national health policy
that will provide equal access to quality health
care. Several major health programs are being
replaced by the new Act including the Hill-
Burton and Regional Medical Programs. To ac-
complish legislative intent the Secretary of
Health, Education and Welfare is to divide all
states into Health Service Areas. Each area
will organize Health System Agencies to carry
out the area health plan.

Under the law Oklahoma could have been
divided into four health service areas — a plan
advocated by many state physicians. Each
Health System Agency is autonomous and can
enter directly into contracts with the federal
government — a violation of state sovereignty
felt those opposed to the multi-area approach.

Governor Boren attempted to accommodate
some of the philosophy of both. With the plan
submitted to Secretary Weinberger, Governor
Boren wrote "I recommend that the entire
State of Oklahoma be designated as one health
service area because this configuration is the
most appropriate area for health planning and
resources development purposes in our State.
My recommendation of a single area is con-
tingent upon acceptance of my recom-
mendation for the creation of regional units,
six in number, which would each be rep-
resented on the governing board of the HSA.
This will provide general coordination while
preserving local input.” Though opting for the

326

single area plan the Governor recognized the
strengths of the multi-area designation. "A
multi-area configuration of four areas with
two rural and two metropolitan was advocated
as the best option to achieve the greatest de-
gree of local control, participation and input
with a consequent decentralization of power
and recognition of the problems of different
areas of the State,” said the Governor’s letter.
However, in continuing to develop his case for
the single Health Service Area the Governor’s
letter stated 'The basic thrust of the law is to
have a geographic area appropriate for the ef-
fective planning and development of health
services. Since the major patient flow and re-
ferral patterns in our state are internal and
directed toward the two metropolitan centers
of our state, a statewide health service area
already exists and such a designation would
ensure the maximum degree of development of
our health care delivery system into an inte-
grated and coordinated network of primary,
secondary and tertiary services. The metro-
politan centers have a responsibility to work in
conjunction with the rural areas to see that
services are provided to the people where they
are most needed. Our health problems in
Oklahoma are statewide in scope and should be
approached as such.

Acceptance of the plan apparently clears the
way for formation of the board and organiza-
tional entity that will contract with DHEW to
perform the functions required by the law.
Consistent with other recent health laws, the
governing board must be representative of the
general public, only forty percent will be
health care providers, the definition of which
includes physicians, dentists, nurses, hospi-
tals, nursing homes, health care and allied
health professionals.

The Board of the HSA has broad respon-
sibilities:

"(1) improving the health of residents of a
health service area,

"(2) increasing accessibility (including over-
coming geographic, architectural, and trans-
portation barriers), acceptability, continuity
and quality of the health services provided
them,

"(3) restraining increases in the cost of pro-
viding them health services, and

"(4) preventing unnecessary duplication of
health resources . . .”

It is anticipated that the HSA Board will be
appointed, staff hired and funded by January,
1976. □

Oklahoma State Medical Association

September

1975

Vol. 68, No. 9

of the Oklahoma State Medical Association

EDITORIAL BOARD

CONTENTS

MARK R. JOHNSON, MD
Editor-in-Chief

HARRIS D. RILEY, Jr., MD
Editor

ROBERT G. TOMPKINS, MD
Editor

editorial

“The Crime of Psychiatric Punishment in the Soviet

Union” 327

President’s Page ....... 328

ERNEST LACHMAN, MD
Corresponding Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

scientific

Metabolic and Hemodynamic Effects on Diphenyl-

hydantoin, S. S. Sanbar, MD, PhD . . . 329

Epidemiology of Bone Cancer In Oklahoma, Jere Bra-

cey, MS and Nabih R. Asal, PhD . . . 336

OFFICERS

special

ARNOLD G. NELSON, MD
President

WILLIAM M. LEEBRON, MD
Vice-President

HAVEN W. MANKIN, MD
Secretary- T reasu rer

Maimonides And His Scene, Solomon Papper, MD . 347

Task Force On Medical Care of the Vietnamese Child 355
News from the Oklahoma State Department of

Health 358

STAFF

DON BLAIR
Business Manager

LOUISE MARTIN
Editorial Assistant

SUBSCRIPTION TO THE JOURNAL is in-
cluded in membership fees. Other subscrip-
tions are $6.50 per year or $1.00 per copy
with each request subject to approval of the
Editorial Board.

news

OSMA Medicare Leaflet Distributed Widely . . 359

AMA Files Lawsuit Against HEW Drug Regulations 360

Death .......... 361

Weinberger Warns About Danger Of Big Govern-
ment ......... 363

Physicians May Report Medically Impaired Drivers 365

Kelsay To Head PSRO Study / . . . . 365

Last Chance For OSMA Hawaii Tour . . . 366

Reaction Time ........ 366

Three New Tours Available To OSMA Members . 368

Immunization Action Month Set For October . 368

Inter-American Symposium On Internal Medicine

Will Convene In Mexico ..... 370

Oklahoma Trauma Society Will Hold September

Symposium ........ 371

Miscellaneous Advertisements ..... 371

Woman’s Auxiliary ....... 372

Index To Advertisers ...... xxxvii

The Last Word ........ xxxvii i

POSTMASTERS: Send all change of address
notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

(Cover Art By William Cason )

Keflex

cephalexin

Additional information available to the profession on request.
Eli Lilly and Company
Indianapolis, Indiana 46206

Oral Suspension

■ -

250 mg. /5 ml.
100 and 200-ml.
^ sizes

125 mg./5 ml.
60, 100, and
200-ml. sizes

100 mg./ml
10-mi. size

250-mg. Pulvules

Oklahoma State Medical Association

editorial

JOURNAL

“The Crime of Psychiatric
Punishment in the Soviet Union”

Students of the Nazi holocaust were under
the impression that the Nazis had exhausted
the range of physical and mental torture and
cruelty. It was left to the Soviet penal system
to add another refinement to the never-ending
range of human brutality. The additional fea-
ture concerns the incarceration of dissenters in
mental institutions. This novel approach in the
handling of non-conforming intellectuals and
political activists started late in 1968 and was
publicized by the famous academician Andrei
Sakharov in 1973. But a recent issue of the
respected British Journal, Nature (November
22, 1974) gives a more detailed picture of this
abuse of psychiatry. It contains an eye-witness
account by Victor Fainberg, who after long re-
tention was allowed to emigrate to Israel and
— at a stop-over in London — provided the
editors with massive background material on
this shattering criminological approach. The
psychiatrists in these penal institutions are of-
ficers of the Soviet secret police and wear un-
iforms that indicate their military rank and
status. Ordinary criminals serve as male
nurses, tormenting the patients and stealing
their food parcels. The medical care for somatic
ailments is completely insufficient and results
in high mortality after acute surgery.

How does a dissident reach such an in-
stitution? Mr. Fainberg was a member of a
human rights group in Leningrad that was in
contact with the Moscow group of Sakharov.
The criteria of selection for psychiatric "treat-
ment” are arbitrary, the alternative being a
sentence in a Soviet labor camp. Fainberg sug-
gests that the psychiatric approach as an al-
ternative punishment is chosen if the ques-
tionable offense, such as contempt of court,
carries a relatively mild sentence. On the other
hand, the culprit selected for compulsory
psychiatric treatment may be retained for an
indefinite period. The diagnosis in general is
schizophrenia. If by chance conflicting

psychiatric opinion is voiced in favor of the de-
fendant, a second psychiatric consultation is
sought that generally conforms with the inten-
tions of the system. In the penal mental hospi-
tal the dissidents are isolated from other pa-
tients and the general handling of the inmates
is harsh. "Treatment” consists essentially of
massive doses of chlorpromazin far in excess of
conventional therapeutic dosages. Other tor-
menting methods are also used. A chemist by
the name of Chinov was subjected to 30 insulin
shocks and additional electro-convulsive
therapy. If the treatment is refused by the pa-
tient, he is subjected to severe physical man-
handling by the orderlies. While the pattern of
treatments varies in different hospitals, it
seems most severe and cruel in the outlying
districts, sheltered from the public eye and
particularly from the foreign press. According
to Fainberg this handling of dissenters is not a
sincere, although misguided, therapeutic at-
tempt to bring maladjusted and disturbed per-
sons back to the social norm, but a deliberate
and cynical exploitation of professional skill
for purposes of isolation and punishment.

What can American and Western European
psychiatry do to prevent such appalling abuses
of their field? Fainberg himself gives us a hint
by stating that the referral of a certain intel-
lectual to a forensic psychiatric institute was
retracted, since at that time a meeting of the
World Congress of Psychiatrists was taking
place in Mexico and the Soviets feared possible
repercussions of world psychiatry. This is con-
firmed in another field, the arts, where the
world renowned cellist Rostropovich, who
emigrated to the West with his wife, a famous
opera star, stated that the reaction of the
Western World is closely watched in the Soviet
Union and may influence their actions. This
makes it incumbent on Western psychiatrists,
again and again to call attention to the de-
scribed criminal abuses of their field in the
Soviet Union and to voice determined protests
at their conventions and in their literature.
Ernest Lachman, MD

Journal / September 1975 / Volume 68

327

president's page

The National Cancer Act
of 1971 clearly established
the conquest of cancer as a
National Priority. In 1972,
our Oklahoma Governor
established the "Governor s
Committee to Combat Can-
cer,” which at this time has
a membership of twenty-
eight. There are twenty
physicians and eight laymen
on the committee. This com-
mittee has been very capably
chaired by Mark Johnson, MD, of Oklahoma City.
The duties of the committee include developmental
work needed to fully exploit existing knowledge
about cancer prevention, detection, diagnosis,
treatment and rehabilitation.

The exact reason that our Governor had in mind
when the committee was formed is unknown by the
writer. This fact is of little or no importance. The
fact is, that a very worth while committee was start-
ed, and it is rendering a great service to at least part
of the people of Oklahoma. It is anticipated that an
even greater service will be rendered to Oklahoma
citizens in the future. Such a program to combat
cancer is long overdue. This program is unique in
that it is one of the first like it in the country.

As always, progress is painful and it takes work
and determination on the part of the committee and
anyone who assists them. The committee has fo-
cused its attention on the more common type cancers
such as cancer of the colon, breast, cervix, uterus,
and prostate. An effort is being made to detect the
high cancer risk individuals. Such information con-
cerning the high risk patient is not only of great
value to the practicing physician, but also to his pa-
tient as well. The physician will be provided with
information nepded to prescribe appropriate preven-
tion, detection, and treatment. It is felt that there is
good reason to expect a significant impact on the
cancer survival rate. The first objective of the com-
mittee has been to develop a practical method of
identifying individuals who are unusual high risks
for cancer.

The committee made the decision to use one area
of Oklahoma as a test area. Pontotoc County was the
area to be used for the first study. Seven thousand,
eight hundred and forty-two questionnaires were
sent out to the residents of Ada, Oklahoma, to indi-
viduals who had reached their 30th birthdays. Of
this group, 2,787 responded. There were 7,093 ques-

tionnaires sent out to the rural Pontotoc county
residents who had reached their 30th birthday. Sev-
en hundred and three responded, making a total of
3,490 respondents, or 23% of the entire group who
received questionnaires. It is the feeling of the com-
mittee that this represents a satisfactory response
during the early stages of this program.

Since that time other organizations have been call-
ed in for their assistance in the operation of this
program. The Oklahoma State Health Department,
the Oklahoma State Medical Association, The
Oklahoma Division of the American Cancer Society,
and the Oklahoma Health Sciences Center now play
an important roll in the operation of this program.
The Governor’s office has continued to lead the way
in the overall committee work. The committee has
received financing from both state and federal agen-
cies. The overall name of the committee has now
been changed to the State Cancer Hospital Network
Program.

The participation of individual physicians is vital
for the success of the program. It is imperative that
the Cancer Hospital Network Program remains as a
committee of the state. None of the participating
organizations should be allowed to take over this
program. It is vital for the success of this program to
remain as it is.

It is estimated that the total incidents of cancer in
Oklahoma in 1975 will be 9,450 cases. Of this group,
it is further estimated that 4,700 will die from their
cancer. From these figures, it is very clear that we
need to improve the survival rate from this dreaded
disease. It is also clear that this cancer detection
program needs to be broadened to cover the entire
state. At a recent meeting of the Cancer Hospital
Network Program, in Shawnee, Oklahoma, many
new directions in which to go were discussed. The
Governor’s Cancer Committee is now being assisted
by hospital administrators, radiologists, chiefs of
staffs of various hospitals, and many other individ-
ual physicians. It has been pointed out by the Gov-
ernor, and by the committee, that each individual
cancer patient should receive the best individualized
care that is available today. This care should be
rendered in an area nearest the patient’s home
where the proper treatment is available. I sincerely
request once again, a unified effort for this impor-
tant purpose.

328

Oklahoma State Medical Association

scientific

Metabolic and Hemodynamic
Effects of Diphenylhydantoin

S. S. SANBAR, MD, PhD

Diphenylhydantoin (Dilantin) ,
anti-conuulsant and anti-arrhythmic drug,
induces hyperglycemia, increases plasma
free fatty acids, and increases carotid
blood flow, despite transient hypotension and

left ventricular failure.

INTRODUCTION

DIPHENYLHYDANTOIN (DPH, DILAN-
TIN) is a well-known anti-convulsant drug1 2
which has been shown recently to be effective
in the management of some cardiac
arrhythmias.3'6 The daily dose of DPH ad-
ministered to human subjects with cardiac ar-
rhythmias has ranged between 5 and 15 mg
per kg body weight.4'9 In dogs and pigs,
experimentally-induced cardiac arrhythmias
have been treated with 5 to 50 mg/kg per
day.10 16

Recently, it has become apparent that large
doses of Dilantin influence carbohydrate and

Work performed in parts at the Department of Internal Medicine, Univer-
sity of Michigan, Ann Arbor, Michigan, and at the US Army Medical and
Nutrition Laboratory, Fitzsimons General Hospital, Denver, Colorado.

From the High Blood Pressure, Hyperlipidemia and Cardiovascular Clinic,
1509 North Rockwell, Oklahoma City, Oklahoma 73127.

Journal / September 1975 / Volume 68

lipid metabolism. In 1965, Belton and
co-workers17 observed that intraperitoneal in-
jection of DPH (70 mg/kg) in rabbits elicited a
substantial increase in blood glucose con-
centration. In the following year, Klein18 re-
ported the first case of DPH-induced hyper-
glycemia. The case was that of a 22-month-old
infant who developed marked hyperglycemia,
glycosuria, convulsions and coma following the
inadvertent oral administration of approxi-
mately 70 to 80 mg/kg over a period of 24
hours; the infant recovered within one week. In
1967, Dahl19 noted the development of hyper-
glycemia and glycosuria in an adult, epileptic,
nondiabetic subject after increasing the oral
dose of DPH from 300 to 700 mg per day; car-
bohydrate metabolism normalized following
reduction of the dose of DPH to 200 mg daily.
In 1969, Goldberg and Sanbar20 reported two
critically ill patients in whom the intravenous
administration of DPH was associated with
marked hyperglycemia and coma; both of them
died. In 1970, Levin et al21 and Kizer et al22
independently reported that DPH inhibits in-
sulin secretion in vitro. In 1973, Levin et al23
showed that DPH inhibited arginine-induced
insulin secretion in patients with mild oral
glucose intolerance, thereby unmasking early
defects of insulin secretion. Finally, in 1974,
Stambaugh and Tucker24 reported that DPH
(600 mg daily) administration to five patients
with symptomatic hypoglycemia, unresponsive

329

Diphenylhydantoin / SANBAR

to dietary management, produced both subjec-
tive and objective improvement in all cases.

With regard to the effect of DPH on lipid
metabolism, Chung and coworkers25’26 re-
ported that intraperitoneal injection of DPH
(25 mg daily) for 10 to 12 days in rats produced
significant reductions in the dermal content of
glycerides and phospholipids, but not choles-
terol. These authors reported also that the
glyceride, but not phospholipid or cholesterol,
content of rat liver and aortic tissue di-
minished significantly after DPH. In 1965,
Chung27 observed in rats that DPH (75 mg/kg)
significantly increased the concentration of
plasma free fatty acid (FFA) in both fed and
fasted states, and that administration of DPH
in combination with epinephrine produced a
synergistic effect in raising plasma FFA con-
centration.

The purpose of this study has been to com-
pare in dogs the acute effects of large intra-
venous doses of DPH on cardiovascular hemo-
dynamics and on the concentrations of plasma
glucose, FFA, cholesterol, triglyceride and in-
sulin, and glucose turnover. Results of this
study have been reported partly in abstract
form.28

MATERIALS AND METHODS

Animals

The experiments were carried out on 20 male
and female mongrel dogs weighing 14 to 21 kg.
After an overnight fast, the dogs were anes-
thetized with pentobarbital sodium (initial
intravenous dose 30 mg/kg) and were kept at
the level of surgical anesthesia throughout the
procedures. Each dog served as its own control
in all experiments.

A 1960 graduate of the Ameican University of
Beirut, Lebanon, S. S. Sanbar, MD, PhD, limits
his practice to his specialty of cardiology and
internal medicine. He is Clinical Assistant Pro-
fessor at the University of Oklahoma Health
Sciences Center. His medical affiliations in-
clude the American Heart Association, the
American Diabetes Association, the American
Federation for Clinical Research, the Cardiac
Society and the Osier Society.

330

Hemodynamic Studies

Hemodynamic studies were carried out on
four dogs. An indwelling catheter was placed
in the cephalic vein for intravenous injections.
A polyethylene tube was inserted in the left
femoral artery, and under fluoroscopic gui-
dance, cardiac catheters were placed in the left
ventricle via the right brachial artery and in
the main pulmonary artery via the left femoral
vein, for measurements of pressures. Statham
pressure transducers were used. Electro-
magnetic flow probes (Micron Instrument)
were placed in the right femoral and right
common carotid arteries. Pressures, the first
derivative of left ventricular pressure curve
(dP/dt) and blood flow were recorded simul-
taneously using an Electronics for Medicine,
Inc, recorder. Following the operative pro-
cedures, each dog was allowed to stabilize for
at least 20 minutes prior to recording the con-
trol values. Subsequently, a single dose of DPH
(25 mg/kg) was injected intravenously over a
period of one-half to one minute.

Metabolic Studies

A medium size catheter (Intracath, C. R.
Bard, Inc., Murray Hill, N.J.) was inserted in
the cephalic vein for intravenous injections
and a polyethylene tube in the femoral artery
for blood pressure measurement and repeated
blood sampling. After a control period of at
least 30 minutes, three dogs received intra-
venously DPH diluent (1 ml/kg), three dogs re-
ceived a single dose of DPH (25 mg/kg), four
dogs received DPH (25 mg/kg) intravenously
after having received DPH (25 mg/kg) intra-
peritoneally 24 hours previously, three dogs
received DPH (15 mg/kg) as a single dose, and
finally three dogs received five injections of
DPH (5 mg/kg) at 30-minute intervals. Each
dose of the drug was injected slowly over a
period of two to four minutes.

In the group of four dogs, two single, intra-
venous injections of 20 juc of high specific ac-
tivity glucose-U-C14 (Nuclear-Chicago) were
administered, the first 60 minutes before and
the second 30 minutes after Dilantin admin-
istration. Fourteen arterial blood samples, 8
ml each, were obtained throughout the
2V2-hour procedure for determination of
specific activity of plasma glucose (see below).
The rates of glucose appearance into and dis-
appearance from the circulation were calcu-

Oklahoma State Medical Association

lated as described by others.29,30 Glucose
turnover was also determined in the three dogs
which received 15 mg/kg of Dilantin. These
dogs received intravenously a priming dose of
15/^cof glucose-U-C14 followed by a constant in-
fusion of 0.191 nc (in 0.382 ml saline solution)
per minute over a period of 2Vz hours, using a
standard infusion pump (Harvard Apparatus
Co, Dover, Mass.). DPH was injected one hour
after starting the infusion of labeled glucose.
Thirteen arterial blood samples were obtained
throughout the procedure for analysis of
specific activity of plasma glucose. Calculation
of rates of plasma glucose appearance and dis-
appearance were carried out according to the
formulas used by Steele.31

Blood samples were mixed with heparin and
placed in an ice-water bath. Plasma was sepa-
rated within half an hour of collection. A por-
tion of the plasma was stored at minus 15° C
for future lipid analyses. In the experiments
where labeled glucose was used, one milliliter
of. the plasma was immediately precipitated
with zinc sulfate and barium hydroxide.32
After standing for 15 minutes the mixture was
centrifuged and glucose was separated from
the supernatant by column chromatography
using an ion-exchange resin, Amberlite
IRA-410.33 The eluate was analyzed for glucose
content32 by a modified Somogyi method as
well as radioactivity, using a liquid scintilla-
tion spectrometer (Nuclear-Chicago). The re-
mainder of the plasma was analyzed subse-
quently for free fatty acids,34 cholesterol,35
triglyceride36 and insulin by a radioimmu-
noassay.*

RESULTS

Hemodynamic parameters

Intravenous administration of DPH diluent
(1 ml/kg) in three dogs did not alter signif-
icantly either the systolic blood pressure or
heart rate. (Fig. 1, left upper) On the other
hand, injection over approximately four min-
utes of DPH (25 mg/kg) in three other dogs
significantly (p<.05) diminished systolic blood
pressure with a maximal decrease of 23 mm Hg
below control values occurring 40 minutes
after injection and a return to control values
occurring after 120 minutes (Fig 1, right
upper); the heart rate was decreased slightly
but not significantly after DPH injection.

'Kindly performed by Doctor John C. Floyd, Department of Internal
Medicine, University of Michigan, Ann Arbor, Michigan.

Journal / September 1975 / Volume 68

Control Dilantin

dilantin diluent 25mg./kg i.v

Fig 1: Changes in arterial systolic pressure, heart
rate and plasma glucose and FFA following in-
travenous administration of Dilantin (DPH) diluent
(left half) and 25 Dilantin 25 mg/kg (right halD in
three anesthetized dogs. Injection time was approx-
imately four minutes. In the significant figures cir-
cles represent the mean values for the groups,
whereas the vertical lines represent the standard
error of the mean (SEM).

Intravenous administration of five injections
of DPH (5 mg/kg) at intervals of 30 minutes
produced in three dogs no significant altera-
tions in either systolic pressure or heart rate
(Fig 2). Each dose was delivered over approxi-
mately two minutes.

The hemodynamic effects of DPH (25 mg/kg)
injected intravenously over a period of one-half
to one minute, are all shown in Figs 3 and 4.
Femoral arterial systolic and diastolic blood
pressure fell precipitously during the first
one-half minute after injection of DPH and
gradually returned toward control values;
mean femoral arterial blood pressure de-
creased from 140 to a minimum of 80 mm Hg.
Left ventricular end diastolic pressure in-
creased from five to a maximum of 13 mm Hg
after one minute of injection, with a return to
control values after 10 to 15 minutes. The peak
of the first derivative of left ventricular pres-
sure curve (dP/dt) decreased by 47% below con-
trol during the first minutes after DPH, with a
return to control values after 15 minutes. Pul-
monary artery pressure increased from 21/11
to a maximum of 33/19 mm Hg. five minutes
after injection, with a return to control values
15 minutes after injection. Finally, femoral ar-

331

Diphenylhydantoin / SANBAR

DILANTIN 5 mg 5 mg 5 mg 5 mg 5 mg

IV DOSE /kg | I

ISO-] Is* — *

Fig 2: Changes in arterial systolic pressure, heart
rate and concentrations of plasma glucose, insulin
and FFA following five injections of Dilantin (DPH)
5 mg/kg injected at intervals of 30 minutes in three
anesthetized dogs. Injection time was approximately
two minutes per injection.

tery blood flow decreased by 40% during the
first one-half minute after injection, but de-
spite maintenance of hypotension, it returned
to control level after five minutes. Carotid ar-
terial blood flow increased by 39% one-half mi-
nute after injection with a return to control
levels after 10 minutes.

Metabolic studies

Intravenous injection of DPH diluent (1
ml/kg) in three dogs produced no significant
alterations in either plasma glucose or FFA
concentrations. (Fig 1, left lower) On the other
hand, injection of DPH (25 mg/kg) in three
other dogs produced significant increments in
plasma glucose and FFA concentrations with
peak values occurring around 60 and 50 min-
utes, respectively; the mean values were still
elevated at the end of the procedure. However,
in these and subsequent experiments, the re-
sponse of plasma glucose and FFA to DPH var-
ied greatly from dog to dog.

Figure 2 depicts in three dogs the effects of
five intravenous injections of DPH (5 mg/kg) at
30-minute intervals. Concentrations of plasma
glucose, insulin and FFA were increased after
the first injection of DPH. Plasma glucose
reached a peak of about 40 mg per cent above
control levels following the third dose of DPH,
and subsequent injections produced no further
increment in plasma glucose. Plasma insulin
concentration showed a biphasic response. It

332

increased after the first two injections, then re-
turned toward control levels; it increased again
30 minutes after the fifth injection of DPH.
Plasma FFA concentration showed a gradual
increase, reaching a peak of about 300 ,u Eq per
liter after the fifth injection of the drug.

Figure 5 shows the metabolic effects of in-
travenous injection of DPH (25 mg/kg) admin-
istered about 24 hours after a similar dose was
injected intraperitoneally. Both plasma glu-
cose and FFA concentration increased signif-
icantly after the intravenous dose, although
the increment in plasma glucose was less
marked than in the group of dogs which re-
ceived only a single large dose of the drug. (Fig
1 ) It is also noted that the rate of fall of glucose
specific activity in plasma did not change fol-
lowing DPH administration, despite the in-
crease in plasma glucose concentration. The
calculated rate of glucose appearance (Ra) into
plasma increased by about 10% above control
levels, while the rate of disappearance (Rd) of
plasma glucose (tissue uptake) decreased by
the same amount; control values for Ra and Rd
were similar, being 3.9 mg glucose per mg per
minute. Finally, plasma triglyceride and
cholesterol concentrations did not change sig-
nificantly during the procedure.

Intravenous administration of DPH (15
mg/kg) in three dogs produced peak increments
in plasma glucose varying between 20 and 62
mg per cent above control levels. (Table I)
Using the technique of a priming injection fol-
lowed by a continuous infusion of
glucose-U-C14, rate of glucose appearance in-
creased immediately after Dilantin injection,
while rate of glucose disappearance did not
change despite the increase in plasma glucose
concentration, indicating a relative inhibition
of glucose utilization.

DISCUSSION

In healthy, anesthetized dogs, intravenous
administration of large doses of DPH produces
transient hypotension, increased left ventricu-
lar end-diastolic and pulmonary artery pres-
sures, decreased dP/dt and femoral artery
blood flow, and increased common carotid ar-
tery blood flow. The changes in pulmonary ar-
tery pressure and carotid blood flow have not
been reported previously. Mercer and Osborne5
have adequately reviewed the cardiovascular
influences of DPH both in animals and in
human beings. Intravenous administration of
DPH both clinically and experimentally is

Oklahoma State Medical Association

Table I

Changes in Plasma Glucose Concentration and Rates of Glucose Appearance and Disappearance
Following Intravenous Injection of DPH (15 mg/kg) in three Anesthetized Dogs

Determination Dog No. Before Injection After DPH

-20'

-10'

15'

30'

45'

60'

75'

90'

Glucose

106

110

112

116

112

Concentration

112

121

149

140

144

145

149

147

119

116

148

181

162

140

127

130

Mean

107

108

110

134

143

139

134

129

± SEM

8.4

7.4

8.3

14.2

20.6

14.6

8.9

10.7

10.1

Rate of

3.6

3.7

3.2

4.6

3.8

3.6

3.1

3.3

Glucose

3.5

3.8

4.6

5.3

3.3

4.0

3.9

3.5

Appearance

4.9

5.2

4.7

7.4

7.8

4.5

3.8

4.8

5.0

Mean

4.0

4.2

4.1

5.7

5.0

4.0

3.8

3.9

± SEM

0.4

0.5

0.9

1.4

0.3

0.1

0.5

Rate of

3.3

3.2

3.6

3.4

3.3

3.4

3.3

Glucose

3.5

3.8

3.4

3.0

4.0

3.6

3.9

3.5

3.7

Disappearance

4.8

5.2

5.0

5.3

6.0

5.5

5.7

4.8

Mean

3.8

4.1

3.9

3.8

4.3

4.2

3.9

± SEM

0.5

0.6

0.8

0.6

0.8

0.4

often accompanied by hypotension which is ap-
parently caused by a combination of direct
myocardial depression, with decrement in car-
diac output, and peripheral vasodilatation.5 37
Our findings in dogs are in accord with these

DILANTIN, 25 mg/kg IV n =4 DOGS

Fig 3: Changes in femoral artery systolic and dias-
tolic blood pressure, left ventricular end diastolic
pressure, first derivative of left ventricular pressure
curve (dP/dt), and pulmonary artery systolic and
diastolic blood pressure following injection of Dilan-
tin (DPH) 25 mg/kg in four anesthetized dogs. Injec-
tion time ranged between one-half and one minute.

earlier reports. Myocardial depression is evi-
denced by a rise in left ventricular end dias-
tolic pressure and a fall in maximal dP/dt. In
addition, the fact that femoral artery blood
flow returned to normal despite hypotension
indicates a diminution in peripheral vascular
resistance. It is also noteworthy that blood flow
in the common carotid increased immediately
after DPH, despite the marked hypotension,
suggesting a direct vasodilatory action of DPH
on the branches of the carotid artery. It cannot
be distinguished from these studies the sepa-
rate effects on cerebral and extracerebral ves-
sels, but if the femoral flow pattern can be con-
sidered as an indication of the extracerebral
carotid flow pattern, the marked early vas-
odilatation must have occurred mainly in cere-
bral vessels. Of interest, coronary blood flow
also increases after DPH.38 With regard to
pulmonary artery pressure, Conn and
co-workers30 administered DPH (2.5 to 5.4
mg/kg) in the pulmonary artery of 12 human
subjects during cardiac catheterization; no alt-
eration in pulmonary artery pressure was
noted. In our studies, larger systemic doses of
DPH produced in dogs a transient increase in
pulmonary artery pressure. It cannot be stated
whether the latter is secondary to depressed

Journal / September 1975 / Volume 68

333

Diphenylhydantoin / SANBAR

DILANTIN, 25 mg/kg I.V
mm of Hg ^

•«°1 FEMORAL ARTERY MEAN PRESSURE

* of CONTROL

CAROTID ARTERY BLOOD FLOW

I I

min 0 1.5 10 15 20 25 30

Fig 4: Changes in femoral artery mean blood pres-
sure and blood flow, and main carotid artery blood
flow in the same dogs depicted in Fig 3.

contractility of the left ventricle, increased
pulmonary resistance or both.

Hypotension was most marked when DPH
(25 mg/kg) was injected rapidly over a period of
one-half to one minute. (Fig 3) When DPH (25
mg/kg) was administered over a period of ap-
proximately four minutes, hypotension was
less marked. (Fig 1 ) And when the same dose of
the drug was injected in five equal doses at
30-minute intervals, hypotension did not
occur. (Fig 2) This emphasizes the importance
of administering slowly the smallest dose re-
quired clinically in order to minimize the re-
duction in blood pressure and the depression of
cardiac performance.

The metabolic studies in dogs show that
DPH increases plasma glucose and FFA con-
centrations. These findings are in keeping
with previous reports by several investi-
gators.1720’27 Using isotope dilution tech-
nics, it has been determined that DPH hy-
perglycemia is associated with a slight in-
crease in rate of appearance of glucose, which
represents primarily hepatic glucose output.40
Furthermore, despite a substantial hyper-
glycemia after DPH, the rate of disappearance
or tissue uptake of glucose slightly decreased
or remained unaltered. These data show,
therefore, that both an increment in hepatic
glucose output and an inhibition of tissue up-
take of glucose contributed to the production of

334

DPH hyperglycemia. The effect of DPH on
plasma insulin is in keeping with the reported
data21 22 indicating inhibition of insulin re-
lease. Further investigations are needed to de-
termine the mechanism by which DPH in-
creases plasma FFA concentrations. The re-
duction in tissue content of glycerides in rab-
bits which received intraperitoneally 25 mg
DPH daily for about 10 days suggests that lipid
mobilization may play a role in raising plasma
FFA. In contrast with the FFA, however,
plasma triglyceride and cholesterol concentra-
tions remained unaltered.

SUMMARY

The hemodynamic and metabolic effects of
large intravenous injections of diphenylhydan-
toin (DPH) were investigated in 20 pento-
barbital-anesthetized dogs. Injection of DPH
diluent in three dogs did not alter blood pres-
sure, heart rate, or plasma concentrations of
glucose and free fatty acid (FFA). Injection of
DPH (25 mg/kg) in four dogs promptly elicited
the following maximal changes: fall in mean
arterial blood pressure of 60 mm Hg; slight de-
crease in pulse; increase in left ventricular end
diastolic pressure from a control of 5 to 13 mm
Hg; 47% decrease in maximal dP/dt (first de-
rivative of left ventricular pressure curve); in-
crease in pulmonary artery pressure from
21/11 to 33/19 mm Hg; 40% decrease in femoral
arterial blood flow; and 39% increase in carotid

min o 30 60 90 120 iso

Fig 5: Changes in plasma glucose concentration
and specific activity, and plasma FFA, triglyceride
and cholesterol following two injections of Dilantin
(DPH) 25 mg/kg at 24-hour intervals in four anes-
thetized dogs.

Oklahoma State Medical Association

blood flow. All hemodynamic parameters ex-
cept blood pressure returned to control values
within 15 minutes. In 13 dogs, injections of
DPH (5 to 25 mg/kg) produced substantial in-
crements in plasma glucose and FFA levels
which persisted over two hours; plasma choles-
terol and triglyceride remained unaltered.
Using glucose-U-C14, the rate of glucose ap-
pearance in plasma increased immediately
after DPH, while the rate of glucose disappear-
ance did not change. DPH hyperglycemia is
thus due to enhanced glucose release and rela-
tive inhibition of glucose utilization.

The findings in dogs that DPH influences
both hemodynamic and metabolic parameters
are compared with similar published inferen-
tial data in humans.

ACKNOWLEDGEMENT

The author wishes to thank Doctors R. Lazzara, F.
J. Conway, A. J. Zweifler, and G. Smet for their
help, criticism and support, and Doctor J. C. Floyd
for performing the insulin levels in his laboratory.

REFERENCES

1. Merritt, H. H., and Putnam, T. J.: Sodium diphenyl hydantoinate in the
treatment of convulsive disorders. JAMA 111: 1068, 1938.

2. Bray, P. F.: Diphenylhydantoin (Dilantin) after 20 years. A review with
reemphasis by treatment of 84 patients. Pediatrics 23: 151, 1959.

3. Harris, A. S., and Kokemot, R. H.: Effects of diphenylhydantoin sodium
(Dilantin sodium) and phenobarbital sodium upon ectopic ventricular
tachycardia in acute myocardial infarction. Am. J. Physiol. 163: 505, 1950.

4. Bashour, F. A., Jones, R. E., and Edmonson, R.: Ventricular tachycardia
in acute myocardial infarction. Preliminary report on the prophylactic use of
Dilantin. Clin. Res. 13: 399, 1965.

5. Mercer, E. N., and Osborne, J. A.: The current status of diphenylhydan-
toin in heart disease. Ann. Int. Med. 67: 1084, 1967.

6. Helfant, R. H., Senffert, G. W., Patton, R. D., Stein, E., and Damato, A.
N.. The clinical use of diphenylhydantoin (Dilantin) in the treatment and
prevention of cardiac arrhythmias. Am. Heart J. 77: 315, 1969.

7. Lang, T. W., Bernstein, H., Barbieri, F., Gold, H., and Corday, E.: Di-
gitalis toxicity. Treatment with diphenylhydantoin. Arch Intern. Med.
(Chicago) 116: 573, 1965.

8. Friedberg, C. K.: Diseases of the Heart. 3rd ed., W. B. Saunders Co.,
Philadelphia, 1966, pp. 533.

9. Karliner, J. S.: Intravenous diphenylhydantoin sodium (Dilantin) in car-
diac arrhythmias. Dis. Chest 51: 256, 1967.

10. Mosey, L., Tyler, M. D.: The effect of diphenylhydantoin sodium (Dilan-
tin), procaine hydrochloride, procaine amide hydrochloride, and quinidine
hydrochloride upon ouabain induced ventricular tachycardia in unanes-
thetized dogs. Circulation 10: 65, 1954.

11. White, C. W., Megirian, R., Swiss, E. D.: The effects of diphenylhydan-
toin sodium glucose and b-diethylaminoethyl diphenylpropylacetate hydroch-
loride on cyclopropane-epinephrine arrhythmias in the dog. Circ. Res. 3: 290,
1955.

12. Covino, B. G., Wright, R., and Charleson, D. A.: Effectiveness of several
antifibrillary drugs in the hypothermic dog. Am. J. Physiol. 181: 54, 1955.

13. Scherf, D., Blumenfeld, S., Taner, D.. Uildiz, M.: The effect of
diphenylhydantoin (Dilantin) sodium on atrial flutter and fibrillation pro-
voked by focal application of aconitine or delphinine. Am. Heart J. 60: 936,
1960.

14. Bose, B. C., Saifi, A. Q., and Sharma, S. K.: Studies on anticonvulsant
and antifibrillatory drugs. Arch. Int. Pharmacodyn. 146: 106, 1963.

15. Lang, T. W., Bazika, V., Pappelbaum, S., Gold, H., Bernstein, H., Her-
rold, G., and Corday, F.: Autotransplanted heart-lung and cerebral venous
shunt preparations: two new technics for pharmacologic assay of cardiovascu-
lar drugs. Am. J. Cardiol. 16: 695, 1965.

16. Zeft, H. F., Whalen, R. E., Ratliff, N B., Jr., Davenport, R. D., and
McIntosh, H. D.. Diphenylhydantoin therapy in experimental myocardial in-
farction. J. of Pharm. and Exptl. Therapeutics 162: 80, 1968.

17. Belton, N. R., Etheridge, J. E., Jr., and Millichap, J. G.: Effects of convul-
sions and anticonvulsants on blood sugar in rabbits. Epilepsia 6: 243, 1965.

18. Klein, J. P.: Diphenylhydantoin intoxication associated with hyperg-
lycemia. J. Pediat. 69: 463, 1966.

19. Dahl, J. R.: Diphenylhydantoin toxic psychosis with associated hyper-
glycemia. California Med. 107: 345, 1967.

20. Goldberg, E. M., and Sanbar, S. S. : Hyperglycemic, non-ketotic coma
following administration of Dilantin (diphenylhydantoin). Diabetes 18: 101,
1969.

21. Levin, S. R., Booker, J., Jr., Smith, D. F., and Grodsky, G. M.: Inhibition
of insulin secretion by diphenylhydantoin in the isolated, perfused pancreas. J.
Clin. Endocrinol. Metab. 30: 400, 1970.

22. Kizer, J. S., Vargas-Cordon, M., Brendel, K., and Bressler, R.: The in
vitro inhibition of insulin secretion by diphenylhydantoin. J. Clin. Invest. 49:
1942, 1970.

23. Levin, S. R., and Reed, J. W., Ching K-N, Davis, J. W., Blum, M. R., and
Forsham, P. H.: Diphenylhydantoin — Its use in detecting early insulin sec-
retory defects in patients with mild glucose intolerance. Diabetes 22:194,
1973.

24. Stambaugh, J. E., and Tucker, D. C.: Effect of diphenylhydantoin on
glucose tolerance in patients with hypoglycemia. Diabetes 23: 679, 1974.

25. Chung, A. C., and Houck, J. C.: Connective Tissue. VI. Dermal lipid
response to diphenylhydantoin. Proc. Soc. Exptl. Biol. Med. 109: 454, 1962.

26. Chung, A. C., Duren, B. Y., and Houck, J. C.: Effect of diphenylhydantoin
administration upon concentration of liver and aortic lipids. Proc. Soc. Exptl.
Biol. Med. 110: 788, 1962.

27. Chung, A. C.: Effects of diphenylhydantoin upon the plasma FFA re-
sponse induced by hormones. Proc. Soc. Exptl. Biol. Med. 120: 217, 1965.

28. Sanbar, S. S., Conway, F. J., Zweifler, A. J., and Smet, G.: Diabetogenic
effect of Dilantin (diphenylhydantoin). Diabetes 16: 533, 1967.

29. Wrenshall, G. A., and Hetenyi, G., Jr.: Successive measured injections of
tracer as a method for determining characteristics of accumulation and turn-
over in higher animals with access limited to blood. Metabolism 8: 531, 1959.

30. Forbath, N., and Hetenyi, G., Jr.: Glucose dynamics in normal subjects
and diabetics before and after a glucose load. Diabetes 15: 778, 1966.

31. Steele, R .: Influences of glucose loading and of injected insulin on hepatic
glucose output. Ann. N.Y. Acad. Sci. 82: 420, 1959.

32. Nelson, N.: A photometric adaptation of the Somogyi method for the
determination of glucose. J. Biol. Chem. 153: 375, 1944.

33. Reichard, G. A., Moury, N. F., Jr., Hochella, N. J., Patterson, A. L., and
Weinhouse, S. : Quantitative estimation of the Cori cycle in the human. J. Biol.
Chem. 238: 495, 1963.

34. Dole, V. P., and Meinertz, H.: Micro-determination of long-chain fatty
acids in plasma and tissues. J. Biol. Chem. 235: 2595, 1960.

35. Connerty, H. V., Briggs, A. R., and Eaton, E. H. Jr.: Simplified determi-
nation of lipid components of blood serum. Clin. Chem. 7: 37, 1961.

36. Van Handel, E., and Zilversmit, D. B.: Micromethod for the direct deter-
mination of serum triglycerides. J. Lab. Clin. Med. 50: 152, 1957.

37. Mixter, C. G., Moran, J. M., and Austen, W. G.: Cardiac and peripheral
vascular effects of diphenylhydantoin sodium. Am. J. Cardiol. 17: 332, 1966.

38. Gupta, D. N., Unal, M. O., Bashour, F. A., and Webb, W. R.: Effects of
diphenylhydantoin (Dilantin) on peripheral and coronary circulation and
myocardial contractility in the experimental animal. Dis. Chest 51: 248, 1967.

39. Conn, R. D., Kennedy, J. W., and Blackmon, J. R.: The hemodynamic
effects of diphenylhydantoin. Am. Heart J. 73: 500, 1967.

40. Hetenyi, G., Jr., Rappaport, A. M., and Wrenshall, G. A.: Effects of
insulin on the tracer-determined distribution and production of glucose in
liverless dogs. Diabetes 12: 150, 1963.

1509 North Rockwell, Oklahoma City, Oklahoma
73127

Remember these dates —

May 6th, 7th, 8th, 9th, 1976
OKLAHOMA MEDICAL SUMMIT 76

Lincoln Plaza Forum Oklahoma City, Oklahoma

This will be a combined meeting of the Oklahoma State Medical Association, the Oklahoma City Clinical
Society and the Oklahoma Academy of Family Physicians.

Journal / September 1975 / Volume 68

335

Epidemiology of Bone Cancer

In Oklahoma

JERE BRACEY, MS
NABIH R. ASAL, PhD

A consistently higher than US age
adjusted death rates for hone cancer have
been reported for Oklahoma males and
females during a twenty-year period studied.

However, these rates appear on the
decline, at least for the white population.
Several counties with high mortality from
bone cancer have been identified in Oklahoma.

The relationship between cancer of the bone
and its suspected causative factors is not well
defined due to a lack of definitive information
about the incidence of the disease in the popu-
lation. The increasing implementation of
tumor registries in the future will afford the
opportunity to remedy this situation through
research. The extremely light coverage of this
topic is evident on a research of the available
literature. Fortunately there are a few well-de-
signed studies with which contrasts and com-
parisons might be made.

In previous studies in England and Wales,
Canada and the United States, perhaps the
most striking factor was the similarity be-

From the Department of Biostatistics and Epidemiology, Division of Public
Health, College of Health, University of Oklahoma Health Sciences Center,
Oklahoma City, Oklahoma

336

tween the age distribution of the adolescent
growth-spurt and bone cancer mortality.1 4’6 7
It is well known that osteosarcoma, a tumor
which occurs mainly in the young, is generally
associated with body sites of maximum growth.
It therefore becomes extremely important to
observe the changes in bone cancer mortality
during the growth and development which oc-
curs at puberty.3 It is also interesting to note
that the incidence of cancer of bone is higher in
males than in females. Osteosarcoma is the
most common type of bone cancer, accounting
for 58% of all confirmed cases.7 Sixty-one per
cent of the tumors occurred in males.6 It has
been noted however that at ages under 45
years the mortality is approximately equal in
both sexes. At ages 45 years and over there is a
sharp increase in the mortality among men but
very little increase in women.4 The male excess
in this group is largely accounted for by tumors
of the ribs and shoulder-girdle.

The Mackenzie study found no significant
difference in the geographical distribution of
bone-tumor mortality.4 This is of interest since
there is a popular hypothesis that bone cancer
might be related to radioactivity in local food
or water supplies. The literature hasn’t pro-
vided convincing evidence to date that would
indicate a definite correlation in practice even
though it is well-accepted that excess radio-
activity might predispose a subject to bone
cancer. Epidemiological studies of low-level
radium 226 exposure have been inconclusive.

In England and Wales during 1951-1953 it
was estimated that the minimum annual mor-
tality was 62.9 per 10,000,000 men and 38.9
per 10,000,000 women.4 Crude mortality rates

Oklahoma State Medical Association

(0 to 64 years) for 1961-1963 were lower than
those estimated from the 1951-1953 data in
England and Wales.1 The male rate (0 to 64
years) was 53.2 per 10,000,000 per year com-
pared with 62.9 per 10,000,000 in 1951-1953.
Female mortality (0 to 64 years) also fell dur-
ing the 10 years, from 38.9 to 33.4 per

10.000. 000 per year.1 In Canada it was found
that the annual mortality rate was 63 per

10.000. 000, 77 for males and 48 for females.6

Tumors of bones other than the limb bones

account for about 30% of the total mortality.4
The mortality rises slowly from birth to ages
20-24 years and then remains fairly level for
the following 20 years. In both sexes, however,
the mortality at ages 20-24 years is slightly
higher than that at ages 25 to 44 years. It is
possible that tumors in this group also show a
growth-spurt peak but it is much less marked
than that found for tumors in limb bones.4 At
older ages the mortality from tumors of bones
other than limb bones rises sharply in men, but
it remains constant in women until age 60-64
years, at which point there is a small increase.

So far there has been no evidence gathered
which would implicate occupational hazards in
the cause of bone cancer. It might be supposed
that the studies on the effects of radiation
would yield some inferences to occupational
exposures but no research has been accom-
plished in this area to date.

METHOD OF PROCEDURE

Mortality data were obtained from death
certificates filed in the Office of Vital Sta-
tistics, Oklahoma State Department of Health.
Information from all resident death certificates
filed between 1950 and 1970 indicating bone
cancer as the underlying cause of death was
transferred to IBM cards for tabulation. (Data
from 1955 were missing.) The international
classification of disease code revised in 1955
and 1965 was used for the purpose of separat-
ing bone cancer deaths from other cancer
deaths. Utilization of both revisions was war-
ranted since the Oklahoma State Department
of Health adopted the 1965 revision during the
1969 and 1970 calendar years.

The data were analyzed according to sex,
race, and year of death for the purpose of estab-
lishing secular trends. Annual death rates by
sex for the total population as well as average
annual death rates for the four five-year
periods (1950-1954, 1956-1960, 1961-1965,
1966-1970) were also computed so that time

Journal / September 1975 / Volume 68

trends could be examined annually and for the
four five-year time periods.

Bone cancer deaths and death rates by age,
sex, and race for the 20-year period studied are
presented so that the distribution of deaths by
the age groups <5, 5-14, 15-24, 25-34, 35-44,
45-54, 55-64, 65-74, and 75+ could be shown
for white males, white females, nonwhite
males, and nonwhite females.

The Oklahoma resident population by age,
sex, race and county was estimated from the
1950, 1960 and 1970 population censuses.

Ideally, we would like to determine whether
the disease frequency formed patterns of ir-
regular distribution or was randomly distri-
buted within the State of Oklahoma among the
seventy-seven counties. Therefore, based on
the mortality experience of the total Oklahoma
population from bone cancer over the 20-year
period studied, the expected number of bone
cancer deaths was estimated for each county
based on the proportion of people in the state
living in that particular county. A standard
mortality ratio was then tabulated for each
county using the observed number of deaths for
the particular county as the numerator and the
expected number of bone cancer deaths as the
denominator. The ratio of observed to expected
deaths was then multiplied by 100 to obtain
the standard mortality ratio for the county. If
the observed and expected number of deaths
are equal, a standard mortality ratio of 100
would be obtained; while an excess of observed
deaths would produce a ratio greater than 100
and thus, indicate an area of excess bone
cancer mortality. Conversely, a mortality ratio
less than 100 indicates an area of low bone
cancer mortality.

Jere T. Bracey received his BA degree in
mathematics and MS in mathematical statistics
from Memphis State University and did one
year doctoral work in biostatistics and
epidemiology at the University of Oklahoma
Health Sciences Center. He is presently emp-
loyed with the US Energy Research and De-
velopment Administration in New Brunswick,
New Jersey.

A 1969 graduate of the University of Okla-
homa, Nabih R. Asal, PhD, is presently Pro-
fessor of Biostatistics and Epidemiology, Divi-
sion of Public Health, College of Health, Uni-
versity of Oklahoma Health Sciences Center. He
is a member of the Society for Epidemiologic
Research and the American Public Health
Association.

337

Cancer / BRACEY, ASAL

RESULTS

Bone cancer deaths by sex, race and year as
well as deaths and rates for the total popula-
tion by year, from 1950 through 1970 (1955
data missing), are presented in Table 1. Aver-
age annual death rates by five-year periods
and for the twenty-year study period are also
presented. It is worth noting from the data pre-
sented in this table that the average annual
death rates for bone cancer are 1.8 and 1.2 (per
100,000) for males and females respectively.
The annual rates in males and females show a
slight decrease in mortality over the twenty-

year period. This decrease is evident if we com-
pare the average annual rates for males for the
1950-54 (2.0), 1956-60 (1.9), 1961-65 (1.7),
1966-70 (1.6) time periods. It is further evident
if we compare the average annual rates for
females for the 1950-54 (1.5), 1956-60 (1.3),
1961-65 (1.2), 1966-70 (0.9) time periods. This
decrease is also reflected in the total number of
deaths occurring in each of the four, five-year
periods. Though rates were not tabulated by
race the data indicate that less than 9.5% of
the total deaths occurred among the nonwhite
population (67 out of 708). The nonwhite popu-
lation is a mixture of blacks and Indians. Of
the total population, whites account for 90.7%
of the population, blacks 6.6%, and Indians

Table 1

Bone Cancer deaths by sex, race and year, and death
rates for the total population by year
Oklahoma, 1950-1970*

(Rates Per 100,000 Population)

Year of

White

Black

Indian

Tot. (deaths)

Tot.

(rates)

death

Male

Female

Male Female

Male

Female

Male

Female

1950

1.9

1.2

1951

2.3

1.6

1952

2.6

1.1

1953

1.6

1.8

1954

1.8

1.7

1950-1954

104

2.0**

1.5**

1956

1.5

1.1

1957

2.0

1.5

1958

1.8

2.0

1959

2.5

1.3

1960

1.7

0.6

1956-1960

100

109

1.9**

1.3**

1961

1.6

1.4

1962

1.3

0.9

1963

1.2

1.4

1964

1.7

1.1

1965

2.9

1.4

1961-1965

103

1.2**

1966

1.9

1.2

1967

1.5

0.8

1968

1.6

0.7

1969

1.4

0.8

1970

1.7

1.1

1966-1970

1.6**

0.9**

1950-1970

376

265

415

293

1.8**

1.2**

*1955 data missing
**Average annual rate

338

Oklahoma State Medical Association

Table 2

Age-Sex-Race Death Rates for Bone Cancer
Oklahoma: 1950-1970*

(Rates Per 100,000 Population)

Age

White Male
1950-54 1956-60

1961-65

1966-70

1950-54

White Female
1956-60 1961-65

1966-70

0.9

1.1

0.9

0.0

5-14

3.2

1.4

2.3

3.9

3.6

3.4

0.5

15-24

3.8

5.2

4.6

5.7

1.3

6.1

1.4

2.7

25-34

0.7

1.5

1.6

2.3

4.1

1.4

0.0

35-44

5.9

4.5

1.5

4.0

1.4

2.1

5.2

0.8

45-54

11.4

13.4

7.2

4.0

6.8

4.8

4.5

2.3

55-64

23.0

22.5

31.5

22.6

22.3

13.0

8.3

8.4

65-74

36.5

25.9

28.6

23.7

28.5

9.3

25.3

11.2

75 +

63.6

72.1

45.1

34.4

42.0

41.4

32.8

34.0

A ADR**

10.1

9.7

8.7

7.5

7.9

5.9

5.6

3.6

Age

Non- White Male
1950-54 1956-60

1961-65

1966-70

Non-White
1950-54 1956-60

Female

1961-65

1966-70

0.0

5-14

0.0

12.1

0.0

3.9

0.0

15-24

0.0

19.2

0.0

8.3

0.0

25-34

0.0

35-44

26.8

9.5

0.0

9.0

0.0

16.7

0.0

45-54

29.8

0.0

10.0

0.0

9.1

17.5

16.9

23.5

55-64

0.0

22.6

31.6

13.4

11.3

10.0

8.5

65-74

0.0

49.3

63.3

13.4

34.2

31.4

14.7

33.3

75 +

36.2

60.6

53.3

7.2

39.4

59.5

24.7

18.9

AADR**

8.1

9.3

9.2

11.1

5.9

8.0

6.8

6.3

*1955 data missing

**Age adjusted death rates based on the 1960 state white males as the standard population

2.7%. Furthermore, the proportional death
rates from bone cancer by race are interesting
in that 90.0% of the deaths occurred among the
white, 7.8% among the blacks and only 1.7%
among the Indian population. Also, the annual
death rates for the white males are approxi-
mately one-and-one half times the female
rates. The same is true for the black males and
females.

In Table 2 we observe bone cancer, age-sex-
race specific death rates by four five-year
periods as well as the age-adjusted death rates
for the white males, white females, nonwhite
males and nonwhite females. It might be
generalized, especially in the white population,
that there is an increase with age to 15 years at
which point the rates drop to age 30 until they
begin to rise at age 40 and then increase stead-
ily with age. The age-adjusted death rates
show a consistent decrease for white males and
females. It is interesting that the age-adjusted
death rates for black males have shown an in-
crease (8.1 to 9.3 to 9.2 to 11.1). The black
females showed a low rate in the 1950-54
period (5.9), a peak in the 1956-60 period (8.0)
and a decrease after 1961 (6.8 to 6.3).

Journal / September 1975 / Volume 68

Figure 1 shows the geographic distribution
of mortality as expressed in standard mortality
ratios. Counties reporting standard mortality
ratios above one hundred reflect an increase in
the observed mortality above that which would
have been expected had the Oklahoma experi-
ence prevailed equally for each of the counties
in the state. Conversely, standard mortality
ratios below 100 reflect a decrease in the ob-
served mortality. Ratios that approximate 100
reflect a mortality experience similar to that
for the state. It is obvious from data presented
in Figure 1 that counties experiencing high or
low standard mortality ratios from bone cancer
in Oklahoma are represented in every geo-
graphic area of the state. However, there ap-
pears to be a number of counties experiencing
unusually high ratios worthy of mentioning.
Beckham county experienced a SMR of about
205, McIntosh 241, Okmulgee 179. These were
significantly high at the 0.05 level of signif-
icance. Beaver county experienced a SMR of
zero, Harper 0, Latimer 0, Oklahoma 73, Tulsa
78, Major 0. These were significantly low at the
0.05 level of significance.

339

Cancer / BRACEY, ASAL

DISCUSSION

The findings of previous studies on morbid-
ity data on bone cancer have been reasonably
consistent in their results. The most obvious
similarity found in the previous studies in the
field is the rapid increase in the bone cancer
death rates from 0-15 years, a decline up to 40
years, and then an increase with age. By age
60 the rates were equal to the earlier peak at
age 15 and then continued rising from age 60
upward. In addition there are differences that
exist in mortality from bone cancer by age, sex,
race. Most of this evidence has been ac-
cumulating from mortality as well as morbid-
ity data.

The findings of this study are consistent with
the general epidemiologic features of this dis-
ease reported elsewhere. The only exception
that is particularly noteworthy, is that the
crude death rates experienced in this study
were considerably higher, but distributed simi-
larly by age as in previous studies. The annual
crude death rate for males, experienced over a
20 year period in this study, was 118 per 10
million and for females 70 per 10 million.
These rates were computed for the 0-64 year
age group. The findings of previous studies

were (0-64 age group — rates per 10 million)
62.9 for males and 38.9 for females4 and 53.2 for
males and 33.4 for females.1 These two sets of
figures are from England and Wales for the
periods 1951-3 and 1961-3 respectively.

Since the cause of bone cancer remains un-
clear, it is not expressly easy to apply descrip-
tive results with meaning. The hypothesis that
the growth-spurt during adolescence accounts
for the increase of bone cancer in those age
groups doesn’t explain why the rates are so
high in the older ages. What meaning can be
placed on the increased rate in males over
females is not clear. The results as to racial
distribution show that the disease is not signif-
icantly higher in one race than another. Why
the disease seems to be increasing with time in
the nonwhite males and very slightly in the
nonwhite females is unclear. Perhaps diagnos-
tic facilities and better medical care are be-
coming more available to this segment of the
population. Bone cancer which was not diag-
nosed in the past is now brought to the atten-
tion of health officials.

There does seem to be a slight trend for the
Indian population to have slightly lower repre-
sentative rates whereas the black population
seems to experience a very slight increase in
mortality. This is not unusual, as the Indian
population is reported to have experienced re-

**Significantly high at the 0.05 level

340

Oklahoma State Medical Association

duced mortality from many other cancer sites
and hence may reflect more the experience of
oriental countries than western countries.

SUMMARY

Deaths from bone cancer occurring to resi-
dents of Oklahoma from 1950 to 1970, ex-
cluding 1955, were analyzed. Age-specific
death rates and age-adjusted rates were tab-
ulated for four, five-year periods by sex and
race. A standard mortality ratio was tabulated
and plotted on Oklahoma maps by county.

A decrease was reported in the annual death
rate for males and females over the 20 year-
period. One and a half times as many deaths
were observed among white and black males as
in the females. In the Indian population the
male-female ratio for bone cancer was unity.

An increase in the bone cancer mortality was
found with an increase in age with a minor

peak at 15-19 years and the maximum being
reached after age 60 — at which point the rates
steadily increased with age.

Another significant finding was the low mor-
tality experienced by the Indian population of
Oklahoma. □

REFERENCES

1. Boyd, J. T., Doll, R., Hill, G. B., and Sissons, H. A. Mortality from Primary
Tumors of Bone in England and Wales, 1961-1963. Brit. J. of Preventive Social
Med., 23: 12-22, 1969.

2. Dahlin, D. C. Bone Tumors, Ed. 2. Springfield, 111.: Charles C. Thomas,
Publisher, 1967.

3. Hems, G. Aetiology of Bone Cancer, and Some Other Cancers in the
Young. Brit. J. of Cancer, 24:208-14, June 1970.

4. Mackenzie, A., Court Brown, W. M., Doll, R., and Sissons, H. A. (1961).
Mortality from primary tumors of bone in England and Wales. Brit. Med. J., 1,
1782.

5. Petersen, N. J., Samuels, L. D., Lucas, H. F., and Abrahams, S. P. An
Epidemiologic Approach to Low-level Radium 226 Exposure. Publ. Hlth. Rep.
(Wash), 81:805, 1966.

6. Phillips, A. J. Canad. Med. Assoc. J., 92:391, 1965

7. Thurman, G. B. Skeletal Location of Radiation-induced and Naturally
Occurring Osteosarcomas in Man and Dog. Cancer Research, 33:1604-1607,
July 1973.

P. O. Box 26901, Oklahoma City, Oklahoma 73190

THE UNIVERSITY OF OKLAHOMA
COLLEGE OF MEDICINE

WEEKLY AFTERNOON OF CONTINUING EDUCATION

FIRST SEMESTER
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This program is acceptable for Category 1 credit toward the Physician’s Recognition Award of the American

Medical Association and the American Academy of Family Practice on an hour for hour basis.

Journal / September 1975 / Volume 68

341

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Oklahoma State Medical Association

Maimonides And His Scene

SOLOMON PAPPER, MD

Maimonides achieved greatness as a
theologian, philosopher and physician.
Selected contributions to each of these spheres
are presented. He demonstrated by example
that medicine should not be a circumscribed
field; rather it is concerned with all truth,
knowledge and wisdom for human purposes.

Maimonides earned prominence among ex-
perts as a theologian, as a philosopher and as a
physician. I shall explore selective aspects of
the man, his times, and his work in all three
areas of knowledge.

It often helps to understand a scholar’s
works if one has some knowledge of personal
motivation and the times in which he lived and
worked; this is certainly true of Maimonides.

THE INTERNAL ENVIRONMENT

Maimonides was a pious Jew with very
Jewish perspectives. Life for him was not di-
vided into religious and secular spheres, but
rather all experience and knowledge, even the
so-called secular were interpreted in terms of
religious outlook. The essence of this particu-
lar religious perspective is unity; the unity

Presented at the History of Medicine Society meeting, February, 1975,

Journal / September 1975 / Volume 68

which necessarily follows from a belief in one
God who willed into being the entire cosmos,
and whose continuing will that it exist is re-
quired to maintain it. If these are the basic
assumptions, it follows that scientific observa-
tions by definition are not and cannot be at odds
with religious experience; and when they ap-
pear to be this is a distortion caused by inade-
quate knowledge. The deeply religious person
in this context is not required to reconcile relig-
ion and science. As he gains knowledge and
wisdom he will inevitably come to learn and
see the oneness and integration of all valid sci-
ence, philosophy and religion. Among the
many with this orientation, Maimonides is
pre-eminent in seeking underlying unity in God
in all knowledge and experience.

It is this total perception that allowed
Maimonides to make a basically religious
statement, which, out of context might be re-
garded by some as irreligious. He said, "The
advancement of learning is the highest
commandment.”

With this as a fundamental aspect of the
internal setting of the man, let us consider
briefly his external environment.

THE EXTERNAL ENVIRONMENT

Maimonides was born in 12th-century Spain,
a time and place of special meaning. In seventh-
and eighth-century Spain, Jews were officially
given slave status, their personal possessions
were confiscated and they were ordered to con-
vert to Catholicism, be executed, or leave the

347

Maimonides / PAPPER

land. It should be no surprise that during that
time Spanish Jews were watching with consid-
erable interest and hope the rise of the Mos-
lems and their dramatic advances over Arabia,
Western Asia, and North Africa. The Moslems
had a record in North Africa of regarding all
Christians and Jews as "protected infidels.”
The Moslem conquest of Spain in the year 711
was therefore welcomed by the Jews and
ushered in for them and the rest of the world
almost seven centuries of relative enlighten-
ment. Division within the world of Islam
placed its Eastern seat in Baghdad and its
Western base in the city of Cordova in south-
ern Spain — the city of Maimonides’ birth.
Under Arab rule, Spain flourished education-
ally, culturally, in agriculture, in science, and
in its standard of living.

While this was happening in Spain, Egypt
under Moslem rule was undergoing a rebirth of
its more ancient glory with considerable im-
provement in the lives of its many Jews. Al-
though discriminatory laws existed in Arab
Spain and Egypt, Jews experienced a measure
of freedom, opportunity, and position they were
not to know again anywhere in the world for
more than 500 years.

One student of this portion of world history
(Abba Eban), wrote:

Four hundred years before the European
Renaissance the lands of the Arab Empire
experienced a rebirth of culture that in
intensity and scope, as well as in the
sheer quantity of its achievements,
equalled, if it did not surpass, any similar
period in human history. In philosophy
and science, in theology, literature and
language, an astonishing range of talent
and innovative genius was applied to the
verbalization of man’s quest to know, and
to the expression of man’s thirst to enjoy.
Blending the knowledge of Greece with
Eastern perspectives, the Arabs further de-
veloped the arts and sciences; under their rule
medicine attained a status unsurpassed until
modern times. The Arab-Jewish interaction in
this era contributed vastly to the history of
civilization and to the subsequent deliverance
of Europe out of the Dark Ages.

THE MAN

Maimonides, born in 1135 in Cordova, Spain,
was a benefactor of this great Arab develop-

848

ment, experienced and survived its dissolution
by the Almohades in Spain to travel to Egypt
where he entered a noble civilization similar to
what Spain’s had been.

Moses ben Maimon, ie, Moses the son of
Maimon was his name. He is also known as the
Maimoni, hence Maimonides. He is also re-
ferred to as RaM BaM from the initials of
Rabbi Moses ben Maimon. (In Haifa, Israel for
example there is the Rambam Hospital.)
Maimonides came from a prominent family of
scholars and communal leaders; his father was
a judge. While little is known of the details of
Maimonides’ early life and education, it is evi-
dent that he learned a great deal of mathe-
matics, astronomy, astrology, philosophy,
theology, Jewish studies and medicine.
Specifically it is not known from whom he
learned medicine. Because of Maimonides’ ear-
lier interest in theology and philosophy and
only later active role as a physician, it has been
assumed that he learned medicine as a
peripheral activity while giving greater em-
phasis to other aspects of learning. His educa-
tion and early life were designed so as to pre-
pare him to follow family tradition as a Rabbi.

In the year of 1 148 when he was 13 years old
his life was badly shaken. The city of Cordova
was the site of a Moslem civil war. The visitors
were the Almohades, a sect who offered Jews
and Christians the alternatives of death or
conversion to Islam. Maimon and his family
illegally fled the city at great risk to them-
selves and began 18 years of wandering over
incredible distances through Spain, Africa and
the Land of Israel. Finally in 1166 at the age of
31, Maimonides arrived in Egypt where he
lived with dignity in a safe haven until his
death at age 70 years. There he first became a
practitioner of medicine, at least in part to
support himself and his dead brother’s family.
His professional reputation expanded rapidly

Certified by the American Board of Internal
Medicine, Solomon Papper, MD, is presently
Distinguished Professor of Medicine at the Uni-
versity of Oklahoma College of Medicine and
Distinguished Physician at the Veterans Ad-
ministration Hospital, Oklahoma City. He is a
Fellow of the American College of Physicians
and a member of the Association of American
Physicians and the American Society for Clini-
cal Investigation.

Oklahoma State Medical Association

and he was soon appointed personal physician
to the Sultan. Maimonides became known be-
yond Egypt and he received and rejected an
invitation to be physician to King Richard I of
England.

Aside from Maimonides’ father, who perse-
vered through the 18 years of wandering only
to die the year the family arrived in Egypt,
relatively little is known of the family. We
know Maimonides had a brother who was a
jewel merchant and who died in a shipwreck
during their years of exile. And we know little
of Maimonides’ mother and wife; and I know
only of vague references to a son.

Similarly little is written of Maimonides’
personality, temperament and disposition;
much has to be surmised. However there is
some evidence that he regarded himself as
sickly most of his life.

But we do know how revered he was in his
time. His greatness did not have to wait for
death or the passage of the centuries to be
recognized.

When Maimonides died, the Jews and the
Moslems of Cairo had public mourning for
three days and in Jerusalem there was a day of
fasting. Legend has it that his body was placed
on the back of a donkey for burial wherever the
body dislodged. He was buried in Tiberias, on
the Sea of Galilee where his tomb remains a
place of pilgrimage. An Egyptian medical his-
torian wrote a poem about him for his funeral:
If the moon would submit to Abu Imram
(Maimonides’) art,

He would heal her of her spots,

Cure her of her periodic troubles,

And keep her from ever waning.

Jews cherished him as reflected in the say-
ing, "From Moses to Moses there arose none
like unto Moses,” with the implication that he
was regarded as a second Moses. Subsequently
the site of his birth in Spain was honored and
named Plazuelce de Maimonides.

THE THEOLOGIAN

In a ten-year period from age 23-33 years,
mostly accomplished during the period of his
wanderings, Maimonides’ first religious work
was completed — he wrote the Commentary on
the Mishna. The Mishna is the compendium of
Jewish Oral Law which includes civil law,
criminal law, ethics, and health matters. It
was written in Arabic, the language
Maimonides preferred although he was also

Journal / September 1975 / Volume 68

fluent in Latin and Hebrew. His most famous
religious work, the Mishna Torah was com-
pleted in the year 1180 at age 45 after ten
years of work. The Mishna Torah is a clarifica-
tion and codification of the whole of Jewish
Laws, topic by topic, arranged systematically
in 14 books. To do this Maimonides had to have
an encyclopedic knowledge of the Bible and the
Talmud. These two religious works established
Maimonides as an outstanding rabbinical scho-
lar called upon by Jews to arbitrate debates
and clarify Jewish Law while serving to ex-
plain for the first time to the gentile world
what Jewish Law was and what it meant.

THE PHILOSOPHER

Although he published his first philosophical
treatise entitled The Art of Logic at age 16 the
crown of his philosophic achievements was not
published until he was 55 years old. It is en-
titled The Guide for the Perplexed and was
written in Arabic. Maimonides intended this
work to be a guide for "thinkers whose studies
have brought them into collision with relig-
ion.” Because of the increasing Arab interest in
Greek philosophies at the time, especially
Neoplatonic Aristotelianism, much of the
Guide interprets biblical and rabbinical theol-
ogy in these terms. The Guide considers the
figurative and literal meanings of the Scrip-
tures; the existence of God, and the nature of
evil, of providence, of the design of nature and
of moral virtues. It shows how Biblical precepts
are intended to perfect man either by impart-
ing knowledge to him, by improving his moral
conditions, or by guaranteeing the well-being
of Society. The Guide also includes an impor-
tant break with Aristotle. The latter accepted
the doctrine of the eternity of the world.
Maimonides rejects this because it puts a limit
on a God who is not tied to the inevitability of
any phenomenon He does not will. This concept
was of major significance to the subsequent
Christian Scholastics.

Let me sample only a few quotes from the
Guide.

The spiritual perfection of man consists
in his becoming an actually intelligent
being . . . Such knowledge can be ob-
tained not by mere virtue and righteous
conduct alone, but through philosophical
inquiry and scientific research.

There are three causes which prevent
men from discovering the exact truth:

349

Maimonides / PAPPER

first, arrogance and vainglory; second,
the subtlety, depth and difficulty of any
subject which is being examined; third,
ignorance and want of capacity to com-
prehend what might be comprehended.

And there is a fourth cause; viz, habit
and training. We naturally like whatever
is familiar, and dislike whatever is
strange . . .

A truth, once established by proof,
neither gains force by the consents of all
scholars, nor loses certainty because of
the general dissent.

He who has studied insufficiently, and
teaches and acts according to his defective
knowledge is to be considered as if he
sinned knowingly.

Do not consider a thing as proof because
you find it written in books . . .

Wisdom is the consciousness of self.

Moral conduct is a preparation for in-
tellectual progress, and only a man whose
character is pure, calm and steadfast can
attain to intellectual perfection . . .

A miracle cannot prove that which is
impossible; it is useful only as a confirma-
tion of that which is possible.

It is of great advantage that man
should know his station, and not erron-
eously imagine that the whole universe
exists for him alone.

It is in the nature of man to strive to
gain money and to increase it; and his
great desire to add to his wealth and hon-
or is the chief source of misery for man.

It is indeed a fact that the transition
from trouble to ease gives more pleasure
than continual ease.

The philosophical and theological works of
Maimonides had an enormous influence on
subsequent Christian scholastic theologians
especially St. Thomas Aquinas and Albertus
Magnus. The resurgence in the 13th century of
the Aristotelian emphasis on purely observ-
able physical phenomena was regarded by
many Christians as a threat to spiritual per-
spectives and true faith. Saint Thomas
Aquinas and Albertus Magnus dealt particu-
larly with the perspective that the "new”
naturalist emphasis could be harmonized and
reconciled with Christian truth. In doing so
they made extensive use of Maimonides’ Guide
for the Perplexed. In fact many of Maimonides’

350

writings were placed for safe-keeping in the
Pope’s library where they still remain.

THE PHYSICIAN

And finally let us turn to something of
Maimonides’ relation to medicine. We have al-
ready indicated his wide reputation as a
practitioner of medicine and his special role as
physician to the Throne in Egypt.

He wrote of his daily routine:

I dwell at Mizr (Fostat) and the Sultan
resides at Kahira (Cairo); these two
places are two Sabbath days’ journey
(about one mile and a half) distant from
each other. My duties to the Sultan are
very heavy. I am obligated to visit him
every day, early in the morning; and
when he or any of his children, or any of
the inmates of his Harem, are indisposed,

I dare not quit Kahira, but must stay dur-
ing the greater part of the day in the
palace. It also frequently happens that
one or two of the royal officers fall sick,
and I must attend to their healing. Hence,
as a rule I repair to Kahira very early in
the day, and even if nothing unusual
happens, I do not return to Mizr until the
afternoon. Then I am almost dying with
hunger. I find the antechambers filled
with people, both Jews and Gentiles, no-
bles and common people, judges and
baliffs, friends and foes — a mixed multi-
tude, who await the time of my return.

I dismount from my animal, wash my
hands, go forth to my patients, and en-
treat them to bear with me while I par-
take of some slight refreshment, the only
meal I take in the twenty four hours.
Then I attend to my patients and write
prescriptions and directions for their sev-
eral ailments. Patients go in and out until
nightfall, and sometimes even, I solemnly
assure you, until two hours and more in
the night. I converse with and prescribe
for them while lying down from sheer
fatigue, and when night falls I am so ex-
hausted that I can scarcely speak.

In consequence of this, no Israelite can
have any private interview with me, ex-
cept on the Sabbath. On that day the
whole Congregation, or, at least the ma-
jority of the members, come to me after
the morning service when I instruct (ad-
vise) them as to their proceedings during

Oklahoma State Medical Association

the whole week; we study together a little
until noon, when they depart. Some of
them return, and read with me after the
afternoon service until evening prayers.

In this manner I spend that day.

While his medical writings were limited to
the last two decades of his life they revealed his
vast knowledge of then current theory and his
own ability to observe, analyze, accept or dis-
card. He was also opposed to non-observational
medicine, and he even criticized Galen whose
stature and influence on Arab medicine were
great. In an era of blind acceptance of the voice
of authority, Maimonides wrote, "Dear is
Galen, but dearer is Truth.”

He elaborated a bit more on the point as fol-
lows:

. . .if any man declares to you (that he
has found) facts that he has observed and
confirmed with his own experience; even
if you consider this man to be more trust-
worthy and highly authorative, be cau-
tious in accepting what he says to you . . .
you should think (critically) and under-
stand (what he means) when he declares
that he has observed it . . . investigate
and weigh this opinion or that hypothesis
according to requirements of pure logic,
without paying attention to his conten-
tion that he affirms empirically. (This is
so irrespective of) whether this assertion
is advanced by a single person or by many
who adhere to that particular viewpoint.
Unlike many if not most of his contemporar-
ies and predecessors, Maimonides had no re-
spect for magic and superstition, and had no
use for astrology which he had studied ex-
tensively. He wrote, ". . .the science of the
stars (ie — astronomy) is a true science.” As-
trology, on the other hand he wrote was, "Not a
matter of science, but sheer stupidity.”

All of his medical works were written in
Arabic, his major language and the language
of science and philosophy of the age.

While there is some doubt about the authen-
ticity of some of his medical writings, there are
ten treatises about which there is no doubt: 1.
Book on asthma; 2. Poisons and their anti-
dotes; 3. Guide to good health; 4. Aphorisms of
Moses; 5. On cohabitation; 6. Commentary on
the Treatises of Hippocrates; 7. On hemor-
rhage; 8. Medical responsa; 9. The names of
drugs; 10. A compendium of the Treatises of
Galen.

I have selected some of Maimonides’ medical
writings to quote and consider with you. For

Journal / September 1975 / Volume 68

convenience I have subdivided these into quite
arbitrary categories according to subject.

First let us consider some of Maimonides’
general attitudes toward medicine.

Maimonides dwelled at length on the
psychological motivation of the true physician
and warned against the bad physician and the
elusive term "experience” as used by the ill-
trained and ignorant physicians and quacks.
He contended that training in the art of medi-
cine should consist of a combination of practice
and theory. This was innovative thinking.

Maimonides considered Medicine more than
a means of conquering disease. It was the art of
healing people. Treatment of the individual, by
taking into account psychological and en-
vironmental factors that were unique in each
and every case, was for Maimonides a pre-
requisite to the patient’s physical and emotion-
al recuperation. He stated that "the physician
should not treat the disease but the patient
who is suffering from it.”

General Health Measures recommended by
Maimonides were:

For the regulation of health, one should
begin with gymnastics, followed by food
and drink, and then coitus and sleep. One
should indulge in each of these five to a
moderate degree.

The most beneficial of all types of exer-
cise is physical gymnastics to the point
that the soul becomes influenced and re-
joices . . . because emotions of happiness
(often) suffice (to heal) just by their pres-
ence. Thus rejoicing and happiness alone
will make many people’s illness milder.
For others, both the illness on the one
hand as well as the emotional upset that
led to it disappear.

It is important to pay more attention to
exercise of the soul than exercise of the
body, according to the higher state of the
soul over the body. One should devote
oneself in all manner of exercise to the
development of happiness, contentment
and rejoicing.

. . .the good foods, that ought to be
adopted by every one who desires the
continuation of his health, are wheaten
bread properly prepared ... it should be
made from fully ripened wheat, dried of
its superfluous moisture . . . The bread
should be made of coarse flour; that is to
say, the husk should not be removed and
the bran should not be refined by sifting.

It should be well raised ... it should be

351

Maimonides / PAPPER

well worked during kneading, and should
be baked in the oven. This is the bread
that ... is the best of foods.

Principles of Therapeutics:

He wrote in the 12th century, that "the clev-
er, skilled physician who is versed in the
fundamentals of medicine and thinks twice be-
fore he decides how to bring about a patient’s
relief, such a man always relies on the work of
nature and keeps her from going lazy.”

Maimonides approached therapy in a man-
ner that is still relevant. He divided therapy
into weak and strong and proposed the use of
the weaker treatments first.

I shall declare what the strong reme-
dies are. They are phlebotomy with the
extraction of much blood; evacuation by
violently attractive purgatives . . .
evacuation by vomiting with the strong
medications . . . the deprivation of
nourishment in its entirety . . . the
prohibition of drinking water and the en-
durance of thirst; taking multiple adju-
vants . . . All these are very strong rem-
edies, and one ought not to have a thing to
do with them except on the advice of a
physician of surpassing knowledge, be-
cause all of these things, when they hit
their mark, cure the sick instantaneously
or within a short time, or deliver them
from death, but if they miss their mark,
they usually kill at once, or they engen-
der an illness that ultimately leads its
host to death; therefore one should be be-
ware of them.

As for the weak medications, they are:
the extraction of blood by scarification of
the legs or the upper parts of the body;
softening me belly with the two mannas;
emesis with barley water, or oxymel;
lightening the food by taking the custom-
ary drinks prepared from sugar, or honey,
or barley water, or kashk of barley, or
soaked bread crumbs, or a little bread in a
broth for the sick; medication with the
healthy medicaments, that is to say,
things that are often taken by the healthy
. . . All these are light remedies; if they
hit their mark they benefit and cure the
mild illnesses, and they can in time cure
severe illnesses. If the miss their mark,

352

they do not kill, or cause great damage;
you find therefore that most physicians
resort to these and their like among the
remedies in seeking security.

The use of medications is pursued as follows:
Whenever it is possible to manage with
a simple medicament they should not
manage with the compounded, and if it is
not possible without the compounded,
they should manage with one of lesser
complexity. They should not resort to
very complex medicaments except when
absolutely necessary. Indeed, it behooves
one to be most diligent and never rush to
the stronger medicament or be inclined to
those that are multiple, but to be content
with what is customary among the lighter
regimes.

Nourishment is considered:

Likewise, when uncertain whether to
feed the sick or prohibit food altogether,
we should feed them with light nourish-
ment . . . One should take a little of what
is customary, and always maintain his
strength by taking nourishment . . .
light nourishment like chicken soup . . .

Surgery:

If one is considering excising something
from the body, one should devote one’s at-
tention in three directions. The first of
these is to complete one’s work in the
shortest possible time. The second is that
no pain should be felt at all during the
surgery, and the third is that one should
be convinced of the outcome. The latter
condition has three prerequisites. The
first is that it should be clear that one’s
intent can be absolutely completed; sec-
ondly, if one’s intent is not (successfully)
completed, the patient should not suffer
any damage from tangential causes, and
thirdly, one should be convinced that the
illness will not return. If one pays heed to
these conditions, then it becomes clear
that sometimes surgical intervention is
more salutory, whereas other times the
use of medications is preferable.

Emotions and Medicine:

It is known . . . that passions of the
psyche produce changes in the body, that
are great, evident and manifest to all . . .
On this account, the physicians have
directed that concern and care should al-

Oklahoma State Medical Association

ways be given to the movements of the
psyche; these should be kept in balance in
the state of health as well as in disease,
and no other regime should be given
precedence in any wise. The physician
should make every effort that all the sick
and all the healthy, should be most cheer-
ful of soul at all times, and that they
should be relieved of the passions of the
psyche that cause anxiety. Thereby the
health of the healthy will persist. This is
also foremost in curing the sick, . . . the
skillful physician should place nothing
ahead of rectifying the state of the psyche
by removing these passions. Nonetheless,
the physician, inasmuch as he is a physi-
cian, should not insist upon his own art as
the rationale for the strategem in remov-
ing these passions, for truly, this virtue is
to be attained from practical philosophy
and from the admonitions and disciplines
of the (Religious) Law . . . people nur-
tured in the philosophy of morals, or in
the disciplines and admonitions of the Law
acquire strength of mind, and they are
truly strong. Their psyche does not
change and is affected as little as possible.
The more a person is disciplined, the less
is his agitation in both these states,
namely, in the state of prosperity and in
the state of adversity.

This servant has only meant by these
references to suggest training the psyche
to restrain the passions by studying books
on morals, the disciplines of the Law and
the admonitions and the laws spoken by
the sages. Thus the psyche will be
strengthened and will see the true as true
and the false as false. The passions will
diminish, the evil thoughts will depart,
the depression will lift, and the psyche
will dilate in whatever situation a man
might encounter. (I note how much of this
perspective is in Dr. Meninger’s most re-
cent book, "Whatever Became of Sin!?”.)

Here contemplation is very good; it will
reduce evil thoughts, anxiety, and dis-
tress. If one reflects on something and be-
comes distressed by the thought, and
grief, sorrow, and sadness arise in him,
this can come from one of two things.
Either he thinks about something that
has passed, like thinking about what has
befallen him from the loss of wealth that
was his or the death of someone for whom
he grieves, or he thinks of things that

Journal / September 1975 / Volume 68

might yet happen and fears their coming,
like thinking and dwelling upon what
might result from the coming of ad-
versity. Yet it is known through rational
observation, . . . that sorrow and gloom
about things that have come and passed
are the occupation of fools. (Note a recent
proverb even sold on greeting cards: 'Do
not allow yesterday to use up today’.)

As for obsession with thoughts about
what might befall in the future that lead
to anxiety, these ought also to be relin-
quished with the consideration that
everything that one might anticipate lies
in the realm of possibility; it might hap-
pen or might not happen.

One who suffers from melancholia can
sometimes rid himself of it by listening to
singing and instrumental music, by
strolling through beautiful gardens and
splendid buildings, by gazing at beautiful
pictures, and other such things that en-
liven the mind and dissipate gloomy
moods.

Thus, just as the body becomes ex-
hausted by hard labor, and is reinvigor-
ated by rest, so is it necessary for the
mind to have relaxation by gazing upon
pictures and other beautiful objects, that
its weariness may be dispelled.

Sickness of the Soul:

It is a well-known assertion of
philosophers that the soul can be healthy
or diseased, just as the body is either
healthy or diseased. These illnesses of the
soul and their health which are alluded to
by philosophers undoubtedly refer to the
opinions and morals of people. Therefore,

I consider untrue opinions and bad mor-
als, with all their different varieties, as
types of human illness. Among these
human illnesses, there is one disease
which is so common that I think that no
one can escape it . . . The illness to which
I refer here consists of the fact that every
individual person considers himself more
perfect than he really is, and desires and
lusts that all that enter his mind should
possess perfection, without effort and
fatigue. (Among sufferers) of this common
illness one finds people who are otherwise
clever and wise . . . Such a person then
gives opinions not only in the (field) he
has mastered, but also in other sciences

353

Maimonides / PAPPER

concerning which he knows nothing at
all, or in which his knowledge is deficient.

I have elected to give less attention to
Maimonides’ writings in specific disorders.
There are however many examples of extra-
ordinary insights: he recognized asthma as
having many etiological aspects including
colds, rhinitis and environmental factors; he
knew a great deal about plant and animal
poisons including a vivid description of
hemolytic and neurotoxic snake venom; and
there are many perceptive observations on the
circulation, diabetes, as well as other condi-
tions.

In summarizing Maimonides the physician
— he apparently was good at the Art of Medi-
cine and had a good knowledge of theoretical
principles of the time. New for his period was
his questioning attitude and the emphasis on
reason and the need for observation — the be-
ginning steps of scientific medicine.
Maimonides was keenly aware of the emotion-
al aspects of medicine. His approach to Medi-
cine was sophisticated, including the elegantly
simple principle to do no harm.

SUMMARY

We can conjecture uselessly whether it was
Maimonides the philosopher that dominated
over the physician, or the physician-scientist
who guided the philosopher. The fact is there
was no compartmentalization in his life; he
preached what he believed to be true, and he
practiced what he preached. Medicine, religion
and philosophy were always closely interwov-
en in all his works. He influenced favorably his
own era and the future of philosophy, theology
and medicine.

The messages for ourselves in learning from
Maimonides are too many to be summarized
and probably are quite individual. For me, the
lessons are that: Medicine is not really a cir-

cumscribed field; we develop through a concern
for human purposes; this development occurs
through serious efforts to acquire knowledge
and wisdom, which in this context include
compassion and justice.

I would like to close with reading the re-
spected Maimonides’ Prayer. It says much of
the man and his profession of medicine:

I begin once more my daily work. Be
Thou with me, Almighty Father of Mercy,
in all my efforts to heal the sick. For
without Thee, man is but a helpless crea-
ture. Grant that I may be filled with love
for my art and for my fellowman. May the
thirst for gain and the desire for fame be
far from my heart. For these are the
enemies of Pity and the ministers of Hate.
Grant that I may be able to devote myself,
body and soul to Thy children who suffer
from pain.

Preserve my strength, that I may be
able to restore the strength of the rich and
the poor, the good and the bad, the friend
and the foe. Let me see in the sufferer the
man alone. When wiser men teach me, let
me be humble to learn; for the mind of
man is so puny and the art of healing is so
vast. But when fools are ready to advise
me or to find fault with me, let me listen
to their folly. Let me be intent upon one
thing, O Father of Mercy to be always
merciful to thy suffering children.

May there never rise in me the notion
that I know enough, but give me strength
and leisure and zeal to enlarge my know-
ledge. Our work is so great and the mind
of man presses forward forever. Thou has
chosen me in Thy grace to watch over the
life and death of Thy creatures. I am
about to fulfill my duties. Guide me in
this immense work so that it may be of
avail. □

921 N.E. 13th Street, Oklahoma City, Oklahoma
73104

Remember these dates —

May 6th, 7th, 8th, 9th, 1976
OKLAHOMA MEDICAL SUMMIT ’76

Lincoln Plaza Forum Oklahoma City, Oklahoma

This will be a combined meeting of the Oklahoma State Medical Association, the Oklahoma City Clinical
Society and the Oklahoma Academy of Family Physicians.

354

Oklahoma State Medical Association

Task Force on Medical Care
of the Vietnamese Child

The American Academy of Pediatrics has es-
tablished an ad hoc task force on Medical Care
of. the Vietnamese Child which met at the
O'Hare Airport on April 21, 1975, to consider
the health problems of these arriving children
and their adoptive families. The task force was
chaired by Henry M. Seidel, MD, Chairman of
the AAP Committee on Adoption and Depen-
dent Care, and included Ruth C. Harris, MD,
Medical Consultant to the Holt Adoption Pro-
gram, Inc., and member of the AAP Adoption
Committee; Donald Lewis, MD, Consultant to
the AAP Adoption Committee; and John D.
Nelson, MD, Consultant to the AAP Committee
on Infectious Diseases and a Consultant to Nhi
Dong Hospital, Saigon.

The task force has been in touch with the
Center for Disease Control and the Bureau of
Community Health Services at HEW, with the
Agency for International Development, and
with physicians in centers where large numbers
of Vietnamese children have recently been
screened. 1,900 Vietnamese children had ar-
rived in the United States at the time of the
meeting, and more were reported enroute. With
this in mind, the task force met to review medi-
cal data available on these children and to alert
physicians who will be caring for these children
to their special medical needs and to important
health considerations as the children enter the
mainstream of American medical care.

The following statement was prepared by the
task force at the conclusion of their meeting. Be-
cause of many requests for this information, the
statement was released to the major media at
that time.

Journal / September 1975 / Volume 68

American Academy of Pediatrics
MEDICAL CARE OF THE
VIETNAMESE CHILD

There has been some expression of concern
about the health of the Vietnamese children
who have recently come to the United States.
This concern has two focuses:

1) the personal health of the individual child;

2) the possible threat to public health in the
United States.

Agencies including the Center for Disease
Control, the Agency for International De-
velopment, and numerous private organiza-
tions and physicians in the United States are
concerned with the arriving Vietnamese chil-
dren and have learned about them as individu-
als and as a group. We have reviewed the
available information and certain things are
clear. There is no evidence at all of any disease
which requires quarantine. There is no evi-
dence at all of any disease which is of a unique
or serious nature which might be introduced
into this country.

Obviously, many of these children — be-
cause of problems of a country at war — are
malnourished and poorly cared for in terms of
both acute and chronic illness. Their acute ill-
nesses are those which are commonly seen in
the United States; but because their chronic
diseases may have received no medical atten-
tion, they may occur in the Vietnamese chil-
dren with greater frequency and intensity than
we customarily see. However, given appro-
priate medical attention these diseases are
manageable or self-limiting. Certainly, one of

355

Vietnamese Child

the major needs is attention to the immuniza-
tion status of these children.

Foresight about probable infections of chil-
dren from underdeveloped countries will ex-
pedite improved health in these children and
prevent disabilities in adopting families. Sur-
veys completed in 1972 of 700 families and in
1974 of over 900 families adopting infants and
children from Asian countries show that 83%
of these children developed acute illness dur-
ing the initial six months. Diarrhea occurred
during the first month in 42%. Persistent prob-
lems include ear (25%) and upper respiratory
infections (28%). Chronic diarrhea due to
parasitic infestations (7%), shigella, sal-
monella, virus infection, and milk intolerance
have occurred. Skin infections have included
eczematoid impetiginous rashes associated
with scabies (1-5%). Like scabies, lice (8%) may
also spread to the rest of the family. Molluscum
contagiosum, staphylococcal boils, styes, and
conjunctivitis (possibly trachoma) have also
been noted.

Intestinal flu, hepatitis, or infectious
mononucleosis has occurred in about 2% of
families within the first four months of the
child’s arrival. Rarely a family has had sal-
monella, shigella, or amebiasis in several
members. It is incorrect to blame the new arri-
val for all family illnesses, but awareness and
special care to prevent spread of infection is
mandatory.

The following are important medical consid-
erations in the evaluation of the Vietnamese
child:

1. Diarrhea and Intestinal Parasites

Bacterial diarrhea: Diarrhea due to
Shigella, Salmonella and E. coli, which ordi-
narily is an acute, relatively brief illness, may
persist in malnourished children. Therefore,
even if a child has chronic diarrhea, these in-
fections are a possibility. Many of these or-
ganisms may be broadly resistant, because of
prior antibiotic administration, so it is impor-
tant to obtain sensitivity tests as well as cul-
tures. These are contagious forms of diarrhea
and call for appropriate precautions including
hand washing, careful disposal of stools, etc.

Parasites: All the Vietnamese children
should have three stool examinations for ova
and parasites, done by competent laboratories.
Parasites commonly present are: hookworm,
Giardia lamblia, ascaris, and ameba.

356

2. Dehydration

On arrival, many of the children have been
found to be dehydrated. Prompt treatment
should be available.

3. Hepatitis

In preliminary observations, heptatis B ap-
pears to be quite common among these chil-
dren, as in children of many developing coun-
tries. We do not recommend routine screening
for hepatitis B antigenemia. Children with
clinical evidence suggesting hepatitis should
have appropriate laboratory tests for con-
firmation of the diagnosis. If hepatitis B is
found in one of these children, gamma globulin
is not recommended for household contacts, as
it is of no value.

In the presence of clinical hepatitis with a
negative test for hepatitis B, the presumptive
diagnosis is hepatitis A, and immune serum
globulin is indicated for household contacts.

4. Tuberculosis

Many of these children will have received
BCG shortly after birth. This commonly leaves
an elevated scar on the arm, thigh, or foot.
Therefore, a positive skin test for tuberculosis
may reflect BCG immunization rather than ac-
tive tuberculosis.

Children with a positive skin test should
have a chest x-ray, but if there is no evidence of
pulmonary or extra-pulmonary illnesss, they
need only be observed and do not require
treatment.

5. Need for immunizations

It is probably prudent to assume that vacci-
nation records may not be accurate, and to per-
form primary immunizations according to
routine schedules on all these children.

6. Dermatitis

Scabies is very common in Vietnamese chil-
dren. In infants, scabies may cause a gen-
eralized rash, rather than the characteristic
pattern, and the skin may not have burrows
but only a papular/vesicular eruption. Treat-
ment with gamma benzene hexachloride
("Kwell”) is effective, and the usual pre-
cautions concerning linen and clothing should
be observed.

Molluscum contagiosum, pyoderma, and
many other skin problems may be present.

7. Pneumonia

Vietnamese children may arrive with lung
infections. Pneumocystis carinii pneumonia
has occurred on rare occasions in severely de-
bilitated Vietnamese orphans.

8. Otitis media

The arriving children may have active mid-
Oklahoma State Medical Association

die ear infections, or evidence of old infections
in the form of perforated eardrums and/or
chronic drainage. Careful evaluation is indi-
cated.

9. Meningitis

Because many of the children have left
under hurried conditions, a number of acute
infections may be incubating, including
meningitis. Again, it is important to remember
that prior, indiscriminate treatment with an-
tibiotics may have been given.

10. Conjunctivitis

Trachoma should be considered in the differ-
ential dagnosis of conjunctivitis. It should also
be kept in mind that conjunctival dryness and
corneal ulcers may be symptoms of vitamin A
deficiency.

11. Chickenpox and Rubeola

It is quite possible that all children may be
carrying these infections.

12. Malaria

Malaria is extremely unusual in infants,
particularly those from Saigon. In unexplained
fevers of older children, malaria should be con-
sidered.

13. Vitamin Deficiency Diseases

These are rather common, particularly ribo-
flavin deficiency.

AMERICAN ACADEMY OF PEDIATRICS
Task Force on Medical Care
of the Vietnamese Child
Henry M. Seidel, MD, Chairman
Ruth C. Harris, MD
Donald Lewis, MD

INTERNAL MEDICINE

An in-depth review course, with emphasis on recent concepts, designed expressly for certification or

recertification in Internal Medicine

1975-76

EVERY THURSDAY 5:00 to 6:30 P.M.

EAST LECTURE HALL

Basic Science Education Building, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma

Developed by The Department of Medicine and The Office of Continuing Medical Education for Physicians

University of Oklahoma Health Sciences Center

Coordinator: Dale Groom, MD

FIRST SEMESTER SCHEDULE

DATE

TITLE

SPEAKER

September 18th

Clinical Pharmacology 1

Thomas L. Whitsett, MD

September 25th

Clinical Pharmacology II

Thomas L. Whitsett, MD

October 2nd

Solid Tumors

Richard Bottomley, MD

October 9th

Hematologic Oncology

Richard Ishmael, MD

October 16th

Immunology 1

Samuel R. Oleinick, MD

October 23rd

Immunology II

Samuel R. Oleinick, MD

October 30th

Neurology 1

John W. Nelson, MD
Donald L. Landstrom, MD
L. D. Amick, MD

November 6th

Neurology II

John W. Nelson, MD
Donald L. Landstrom, MD
L. D. Amick, MD

November 1 3th

Hyperlipoproteinemia

Thomas F. Whayne, MD, PhD

November 20th

Genetics

J. Rodman Seely, MD

December 4th

Bleeding Disorders

Richard Marshall, MD

December 1 1th

Rheumatology

Russell T. Schultz, MD

December 18th

Allergy/Immunology

James H. Wells, MD

Registration fee: $35.00

This continuing medical education activity is acceptable for 1 V2 hours per session in Category I for the Physician's Recogni-
tion Award of the American Medical Association and the American Academy of Family Physicians.

The University of Oklahoma is an Equal Opportunity Institution

Journal / September 1975 / Volume 68

357

Oklahoma Immunization Action
Month, October, 1975

The goal of the Immunization Program is to
locate and immunize susceptibles to diseases
preventable through immunization-measles,
rubella, polio, diphtheria, tetanus and pertus-
sis. To achieve this goal, a major immunization
awareness campaign has been scheduled for
October, 1975. This campaign is a part of the
National Immunization Action Month Pro-
gram sponsored by the Center for Disease Con-
trol and supported by national, state and local
medical associations, voluntary action groups
and pharmaceutical companies.

The IAM awareness program is designed to
increase the immunity level of Oklahoma’s
preschool children by placing increased re-
sponsibility for adequate immunizations on
physicians and parents. Physicians will be en-
couraged to audit their patient’s immunization
records. Each time a record is pulled, the vac-
cination status of the patient should be deter-
mined. If the patient is susceptible to the dis-
eases in question arrangements for vaccination
should be made. Parents will be encouraged to

News From
The Oklahoma State
Department of
Health

perform their own vaccination audits of their
children. If there are questions, parents will be
asked to contact their physician or public
health offices for assistance.

The major emphasis of the October Immuni-
zation Action Month Program will be directed
toward 1-4-year-old children. The program will
encourage a systematic review and updating of
the immunization status of those currently in
private or public health care systems. IAM will
motivate, encourage, influence or otherwise di-
rect those who are currently not in one system
or the other to enlist in such a system.

The success of Oklahoma’s Immunization
Action Month, October, 1975, will depend
heavily upon physician participation. You can
support this effort by reviewing your patient’s
immunization records and reminding parents
of the need for vaccination of susceptible chil-
dren. □

COMMUNICABLE DISEASES IN OKLAHOMA FOR JULY 1975

DISEASE

July

1975

July

1974

June

1975

Total To Date
1975 1974

Amebiasis

Brucellosis

—

Chickenpox

944

800

Encephalitis, Infectious

Gonorrhea (Use Form ODH-228)

1133

1057

1112

7254

6284

Hepatitis, A, B, Unspecified

495

643

Leptospirosis

—

Malaria

—

Meningococcal Infections

—

Meningitis, Aseptic

Mumps

173

358

Rabies in Animals

Rheumatic Fever

—

Rocky Mouhtain Spotted Fever
Rubella

—

Rubella, Congenital Syndrome

—

Rubeola

125

Salmonellosis

102

141

Shigellosis
Syphilis, Infectious

196

(Use Form ODH-228)

Tetanus

—

Tuberculosis, New Active

192

194

Tularemia

Typhoid Fever

—

Whooping Cough

358

Oklahoma State Medical Association

news

OSMA Medicare Leaflet Distributed Widely

To My Medicare Patients

Your Medicare Benefits
Are Being Cut

Your Medicare reimbursement is
now being cut drastically! This reduc-
tion in Medicare benefits was brought
about by the recent application of a
1972 federal law.

Public Law 92-603 instructed the
Secretary of Health, Education and
Welfare to roll back Medicare pay-
ments toward doctor bills to the
amounts physicians were charging in
1969andl970,plusa small yearly in-
crease to be set by the Secretary.

The Secretary has now ruled that
the maximum increase in the Medi-
care reimbursement for physicians'
fees will be only 17.9% over 1970
levels. This unfair reduction in your
Medicare benefits is made all the
more obvious when you consider that
in the same time period the cost of
living has increased more than 43%,
housing costs have gone up more
than 46%, the cost of transportation
has increased 34% and food has in-
creased 57 %!

Because of this benefit reduction
you will begin to see the phrase
"more than the allowable charge"
appear more often on your Medicare
benefit explanation form. Please
understand that the "allowable
charge" referred to is the reduced
amount that Medicare has decided it
will pay for your medical care.

In announcing the reimbursement
rollback the Secretary of HEW stated
that it will save the federal govern-
ment approximately $26 million in
1 976. What he failed to point out was
that this $26 million will have to be
paid out of the pockets of persons on
Medicare, the very persons that the
program was designed to help.

The Secretary apparently ignored
the fact that the Medicare eligible
population of this coun+ry, those 65
years of age or over, are the ones
traditionally living on a limited or
fixed income.

If you are concerned, write your
Congressman, U.S. Senators and the
President of the United States in care
of Washington, D. C., to protect your
interests.

"Your Medicare Benefits Are Being Cut,” is
the headline on a leaflet being distributed by
all OSMA members to their Medicare patients.
The initial supply of 150,000 leaflets was
quickly exhausted.

The leaflet, or statement stuffer, was pre-
pared by the OSMA’s Public Policy Council
and response to new Medicare regulations that
will result in a rollback of federal reimburse-
ments to Medicare beneficiaries for physician
expenses.

Journal / September 1975 / Volume 68

Initially 100 of the leaflets were sent to
every OSMA member along with a reorder
form. Within two weeks after the first distribu-
tion, orders for nearly 100,000 additional leaf-
lets had been received in the OSMA office.

The leaflet was designed to warn Medicare
recipients that their reimbursements would be
cut because of new regulations being published
by the Health, Education and Welfare De-
partment based on a section of Public Law
92-603. That law provided that Medicare car-

359

news

riers prevailing charge screens for fiscal year
1973 would serve as the base for measuring all
future increases in payments. The charge
screens for fiscal year 1973 were based on
charge data collected during calendar year
1971. Overlooked, however, was the fact that
physicians were in a fee freeze status at that
time and their fees were actually those that
prevailed in 1969 and 1970.

The net result of the law, combined with the
fee freeze, and regulations published by HEW,
was to rollback many Medicare reimburse-
ments to the "so-called” 1973 level plus a max-
imum increase of 17.9 percent over that
amount.

Medicare carrier officials have estimated
that as high as 80 percent of all physician fee
reimbursements will be cutback. □

AMA Files Lawsuit Against
HEW Drug Regulations

A lawsuit to block the implementation of
new federal drug regulations that would pres-
sure physicians to prescribe low cost drugs for
Medicare and Medicaid patients has been filed
by the American Medical Association.

The regulations, known as Maximum
Allowable Costs (MAC) were approved in final
form by HEW Secretary Caspar Weinberger a
few days before he left office. Within 24 hours
the AMA filed suit in Federal District Court.

While contending the program is the epit-
ome in regulatory control, the AMA referred to
MAC as "an impossible labyrinth of drug regu-
lations without assuring a favorable cost-bene-
fit ratio”.

The AMA contends the constitutional rights
of both patients and physicians would be viol-
ated and that the program would produce ad-
versary relationships among physicians, pa-
tients, and pharmacists.

The disputed regulations would require
pharmacists filling prescriptions for
Medicare-Medicaid patients, primarily Medi-
caid, to be reimbursed on the basis of the low-
est cost at which the product is generally
available to providers.

Provision was made for a physician to re-
quire a higher-priced drug reimbursement if
he would state that the drug was "medically
necessary.” The obvious purpose of the regula-

360

tions is to stimulate purchase of generic drugs
and discouraging purchase of brand names
that carry higher costs.

Since there is no substantial outpatient ben-
efit for Medicare, physicians primarily will be
affected as they deal with Medicaid patients. In
states with anti-substitution laws, a Medicaid
prescription for a brand name drug more ex-
pensive than the MAC regulations would allow
would mean that the patient would have to
make up the difference in price unless the
physician would be willing to change the pre-
scription to another brand or generic prescrip-
tion or sign that it was medically necessary.

HEW has predicted that most physicians
will go along with a program, estimating that
one-half of one percent would use the "medi-
cally necessary” route for brand names that
exceed the MAC regulation allowables.

The AMA lawsuit argues that the regula-
tions "violate every one of the drug-
reimbursement requirements of the Medi-
care-Medicaid statutes” and defy the law in-
asmuch as they represent government inter-
ference with medical practice by telling physi-
cians which drugs they should prescribe.

Secretary Weinberger estimated the MAC
program would save federal and state govern-
ments between $60 and $75 million a year
when it swings into full operation within three
to four years.

In addition to the control program, HEW will
send all physicians a list of most frequently
Drescribed drugs along with the prices com-
munity pharmacies pay for them. The aim is to
encourage physicians to prescribe cheaper
products in their regular, private practice.

While no sanctions are provided for physi-
cians, to indicate that their prescription for a
brand name is "medically necessary,” HEW
officials speculated that state health agencies
might take a closer look at physicians who do
this consistently for all their Medicaid pa-
tients. According to HEW officials, the possible
penalty by the state would be ouster of the
physician from Medicaid participation.

Before a maximum allowable cost can be
established for a drug, the Food and Drug Ad-
ministration must rule out the possibility that
there is a bioequivalence problem among its
several brands. The HEW Pharmaceutical
Reimbursement Board would then propose a
MAC at a level equal to the lowest cost at
which the drug is generally available to pro-
viders.

Oklahoma State Medical Association

Before the MAC can officially be established
on any drug it must be reviewed by a non-gov-
ernmental advisory committee and published
in the Federal Register for comment.

HEW has stated that one-quarter of com-
monly prescribed drugs are available for mul-
tiple sources. However, the number for which
bioequivalence problems can be ruled out is
smaller.

The reimbursement that a pharmacist re-
ceives for drugs he provides Medicare and
Medicaid patients will be based on an estimate
of his cost of buying the drug plus a dispensing
fee, or on his usual charge to the general pub-
lic, whichever is the smaller. State Medicaid
programs would make the estimates according
to price information supplied on a regular basis
by HEW.

The MAC regulations as published in final
form were somewhat changed from the original
proposal. At first it was recommended that
exceptions would be made only if physicians
certified the drug was the only one effective or
that could be tolerated by the particular pa-
tient. An FDA official said that this particular

section was changed because of objections from
the American Medical Association.

When the regulations were published in the
Federal Register over 2,600 comments were
filed with HEW. Of that number, less than 300
were favorable. □

DEATH

WILLIAM A LOY, MD
1913-1975

A long-time Pawhuska physician,
William A. Loy, MD, died in Oklahoma
City, August 8th, 1975. Born in Enid,
Oklahoma, Doctor Loy was graduated
from the University of Oklahoma Col-
lege of Medicine in 1937, where he
later became a faculty member. Doctor
Loy practiced in Pawhuska from 1946
until his retirement in 1972. He had
served as District Chairman of the US
Medical School Alumni Association.

Doctor Loy was awarded a Life
Certificate by the OSMA in 1973. □

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Journal / September 1975 / Volume 68

361

Take advantage of the off season rate.
Combine your education & your vacation.

Southern Medical Association

69 i Annual
Scientific Meeting

Miami Beach, Florida -Hotel Fontainebleau
, Nov. 18-19, 1975

But we will tell you about the most ex-
citing scientific medical meeting of the year
- the 69th Annua! Scientific Meeting of the
Southern Medical Association - featuring
a wide range of symposia, 22 sections, live
teaching demonstrations, learning center,

postgraduate courses, closed-circuit televi-
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The Continuing Education Program of
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Education.

The best of two worlds is awaiting you.

Make your plans now while reservations
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362

Oklahoma State Medical Association

Weinberger Warns About Danger
Of Big Government

Caspar W. Weinberger showed a more
conservative side when he was on his way out
as Secretary of Health, Education and Welfare.
While usually cited as a liberal bureaucrat, the
last address he delivered as Secretary of HEW
was to warn the nation about the dangers of an
"all pervasive federal government.”

In an address to the Commonwealth Club of
San Francisco, the outgoing Secretary made it
clear that he is strongly and personally op-
posed to the growing welfare state. The follow-
ing are excerpts from his prepared remarks:

"My single overriding observation after
these years in Washington is of the growing
danger of an all pervasive federal government.
Unless checked, that growth may take from us
our most precious personal freedoms. It also
threatens to shatter the foundations of our
economic system.

"We are . . . creating a massive welfare
state that has intruded into the lives and per-
sonal affairs of our citizens. This intrusion af-
fects both those it seeks to help and those who
do the helping. The entire human-resources
field is under the lash of federal law — doctor,
hospital, teacher, college president, student,
voluntary agency, city hall, and state capitol.
All of these are subject to the steadily increas-
ing intrusion of the Congress, which requires
that drastic and often unnecessary regulations
be adopted by the Executive Branch.

"It must be emphasized that this increased
intrusiveness is a consequence of legislation
not the impulsiveness of the Executive Branch.
I had to plead with the Congress to grant a
special exemption for Boy Scouts and Girl
Scouts from the broad sweep of Title IX the
Antisex Discrimination Statute. Yet I venture
to say that there is scarcely a person in this
audience who does not believe it was all the
idea of the Department of Health, Education
and Welfare rather than the poorly drafted
statute Congress passed, which, unamended,
would have required Girl Scout troops to admit
boys and vice versa.

"There is an overriding danger inherent to
the growth of an American welfare state. The
danger simply is that we may undermine our
whole economy. If social programs continue
growing for the next two decades at the same
pace they have in the last two, we will spend
more than half of our whole gross national

product (GNP) for domestic social programs
alone, by the year 2000.

"Should that day ever come, half of the
American people will be working to support
the other half. At that point, government
would be like a gigantic sponge, sopping up all
the nation’s surplus capital needed for indus-
trial growth and modernization. Lacking funds
for those vital purposes, we would no longer
have enough surplus capital left to invest in job
reducing activities in the private sector, and it
is that kind of investment which has always
pulled us out of recessions and depressions in
the past. In all likelihood, we could not main-
tain our free enterprise, incentive capitalistic
economy, if 50 percent of the whole group GNP
had to be used to pay for domestic social pro-
grams alone. And if we lose our free-enterprise,
incentive system, we will have destroyed, by
inaction, the system that has brought more
benefits to more people at home and throughout
the world than any other system since recorded
history began.

"Those who urge still more social programs
view the problem upside down. It is not more
social programs that will solve our nation’s ills
but more economic growth. Growth alone pro-
vides the jobs that reduce social ills. Growth
alone, provides the revenues that finance our
social program commitments, yet one of the
most iniquitious of the new philosophies we
hear today is the smug assertion that 'less is
better and more is worse’.

"What we do have to limit is the growth of
the welfare state in America. We must sum-
mon up a common determination as a people to
change drastically our present approach be-
cause it is not only not working, but it can ruin
all of us. Only a wave of public sentiment in
this direction can give Congress the nerve to
say 'no’ to more social programs. As it is, Con-
gress quite evidently believes that the road to
popularity and reelection is to say 'yes’ to every
demand for every increase in all existing pro-
grams and to agree to most demands for new
ones.

"The federal government has been spending
more than it has taken in; fifteen of the last
sixteen federal budgets have been red ink bud-
gets. If we continue thus, the nation will also
stand before the abyss someday, only there will
be no one with enough resources to rescue the
federal government. This need not be the re-
sult. Always before we had the sense, the wis-
dom and resolution to change course in
time.” □

Journal / September 1975 / Volume 68

363

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Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

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For additional details and application form, please contact

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Administrator

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P.O. Box 18593 Oklahoma City, Oklahoma 73118

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OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848-7661

364

Oklahoma State Medical Association

Physicians May Report
Medically Impaired Drivers

Physicians now have immunity from legal
action if they report patients with health prob-
lems that make them potentially dangerous
drivers.

In the closing days of the last Legislature,
Senate Bill 296 was passed. This bill provides
that physicians treating individuals "for any
illness or injury that would impair the ability
of the individual in any manner as to affect the
performance of the person to operate a motor
vehicle” may make a written report of the
diagnosis to the Department of Public Safety’s
Drivers License Medical Advisory Committee.

Any physician making such a report, so long
as it is done in good faith and without negli-
gence or malice, is granted immunity for civil
liability for their acts.

When such a report is received, the Medical
Advisory Committee of the Public Safety De-
partment, comprised of seven physicians, re-
views the case and makes the recommenda-
tions to the department.

Physicians have had the right to report
potentially dangerous drivers for many years.
However, they seldom did because of the fear of
lawsuits. The law, as originally written, did
not contain the section providing immunity
from civil liability.

R. B. Carl, MD, representing the OSMA,
testified to the Legislature that he believed
there was a need for such a law for "the rela-
tively few times when a patient is uncoopera-
tive, or when, because of his disability or brain
lesion, his judgment is such that he cannot be
reasoned with.”

Leroy Carpenter, MD, State Commissioner
of Public Health, and Secretary of the Medical
Advisory Committee wrote, "I have seen sev-
eral hundred cases where a physician has de-
sired to report a driver whose physical condi-
tion is detrimental to himself or the safety of
others on the highway. However, most physi-
cians are reluctant to report . . . because of
potential liability.”

Another section of the same law provides
that any reports, or the transcripts of proceed-
ings resulting from such reports, shall not be
entered in evidence in any other type of hear-
ing, except for the purpose of revocation, sus-
pension, cancellation or denial of an
individual’s drivers’ license. Such records are
not to be considered "public record.” □

Journal / September 1975 / Volume 68

Kelsay To Head PSRO Study

Ed Kelsay has been chosen by the Oklahoma
Foundation for Peer Review, Inc., to serve as
the Foundation’s Executive Director and as
Project Director for a Professional Standards
Review Organization Planning Contract for
the State of Oklahoma. The contract was en-
tered into by the foundation at the direction of
the OSMA House of Delegates and Board of
Trustees.

The employment of an Executive Director is
the first action of the Foundation to fulfill its
one-year Planning Contract with HEW.

The new Executive Director is best known to
Oklahoma physicians as one of the Associate
Executive Directors of the Oklahoma State
Medical Association. He is an attorney and is
an adjunct professor of Medical Law, Ethics
and Economics at the OU Health Sciences Cen-
ter.

In a recent interview the new Executive
Director stated, "It is now obvious to all parties
concerned that PSRO, as originally envisioned,
was an ill-conceived program that would
directly interfere with the practice of medicine
and significantly add to the health care costs of
the nation. The stated aim of PSRO is to in-
crease the quality and quantity of medical care
while restraining costs. It is our desire, in
Oklahoma, to formulate a program that will
carry out that aim without damaging the qual-
ity of care, interfering in the doctor-patient re-
lationship or increasing the costs.

"A perfunctional reading of the original law
and the published PSRO regulations would in-
dicate that the Health, Education and Welfare
Department felt that the only way the aims
could be carried out was by a constant monitor-
ing of physician practice via a bulky
bureaucracy followed up by a constant
computerized check and double check on all
services rendered. We think it’s possible to ac-
complish the stated purpose of PSRO without
such physician vexation and bureaucratic ex-
pense by relying on continuing education.”

During the next year the foundation will be
seeking input from every physician in the state
to assist it in preparing a plan for presentation
to HEW. Hillard E. Denyer, MD, Chairman of
the Foundation’s Board of Directors stated, "we
want our plan to be a 'physicians’ plan’, based
on the principles of good medical practice and
not a 'bureaucrats’ plan’ based on a misconcep-
tion of the practice of medicine.” □

365

news

Last Chance For OSMA
Hawaii Tour

Oklahoma physicians have one more chance
to sign up for the OSMA sponsored tour to
Hawaii for the American Medical Association’s
1975 Clinical Session.

Although the tour is nearly full, physicians
still have an opportunity to select one of two
departure dates from Oklahoma City, either
November 27th or 28th. Those leaving earlier
will pay only $25 extra for the entire tour. All
physicians will return to Oklahoma City on
December 7th.

The per person price for the tour is $589 and
includes roundtrip jet airfare from Oklahoma
City to Honolulu and return with economy
class seating via Braniff 747. The price also
includes inter-island airfares. Seven nights
superior class accommodations at the Hawaii
Regent Hotel in Honolulu and two nights de-
luxe accommodations at the Maui Surf Hotel in
Maui.

The six-day seven-night stay in the Hawaii
Regent will give all physicians an opportunity
to attend the entire AMA Scientific Meeting,
November 30th through December 5th. In ad-
dition, the scientific program is being prepared
for the two extra days stay on Maui.

An optional two-day tour to the Mauna Kea
Beach Hotel on the big island of Hawaii is
available in place of the two-day stay on Maui.
This particular hotel was developed by Law-
rence Rockefeller and has frequently been de-
scribed as one of the greatest resorts in the
world. A $55 per person additional charge is
necessary for the Mauna Kea option.

Most of the American Medical Association’s
scientific program during the Clinical Conven-
tion has been arranged between the hours of
7:15 a.m. ^nd noon each day. This allows
Hawaii visitors their afternoons and evenings
to enjoy the wonders of Honolulu. Post-
graduate topics include hyperlipodemia, pul-
monary function tests, newer antibiotics, basic
and advanced EKG, dermatology for nonder-
matologists, peripheral vascular disease, infec-
tious diseases in children, pitfalls of emergency
room x-rays, and many, many others.

Anyone wishing to participate in the ten-
day tour should contact the OSMA office by
telephone immediately. Area Code 405-842-
3361. □

366

Arnold G. Nelson, MD
President

Oklahoma State Medical Association
601 N.W. Expressway
Oklahoma City, Oklahoma 73118

Dear Doctor Nelson:

Please convey to the Board of Directors and
membership of the Oklahoma State Medical
Association my most grateful thanks for their
efforts in connection with our Health Pro-
fessions Student Loans. The check just re-
ceived in the amount of $2,735 brings the total
OSMA contributions to $11,000. On a one-
ninth matching basis these contributions have
enabled the College of Medicine to secure
$99,000 in federal loan funds over the past
three years. The following points are impor-
tant and you may wish to convey them to your
members:

1. All of the funds are loaned to medical stu-
dents with the eventual repayment of those
funds being reloaned on a revolving basis to
other students. In effect, then, the real worth of
the contributions can be measured in terms of
the number of loans made from a perpetual re-
volving account over an indefinite period.

2. Added to the $11,000 contributed by the
OSMA the total amount made available was
$110,000.00.

3. Our Regional Office informs us that any
new legislation will not contain appropriations
for Health Professions Scholarships, which
means that unless a student wishes to
negotiate a return service contract, he must
borrow the full amount of his need each year.

You can see how tremendously important
this program is to the students in the College of
Medicine and why we are so appreciative of
your efforts.

Best regards.

Sincerely,

Thomas N. Lynn,

Acting Dean

Oklahoma State Medical Association

BEVERLY HILLS HOSPITAL
BEVERLY HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

PSYCHIATRY

Jackson H. Speegle, MD Fred H. Jordan, MD

John T. Holbrook, MD Joseph H. Lindsay, MD

PSYCHOLOGY

George R. Mount, PhD Tom I. Payton, MS

Donald L. Whaley, PhD Patrick R. Barnes, MS

EDUCATION DIRECTOR

William E. Nix, PhD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND R.T. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

Journal / September 1975 / Volume 68

367

news

Three New Tours Available
To OSMA Members

1976 will be an international travel year for
OSMA. The association has contracted for
three tours to be made available to its mem-
bers.

All three of the tours will be conducted by
INTRAV, one of the nation’s largest group
travel organizations.

The first 1976 tour will be a nine-day eight-
night, land tour of Central America known as
the "Mayan Adventure.” This tour will depart
from Oklahoma City on January 7th and will
be co-sponsored by the Rocky Mountain Medi-
cal Group, medical doctors from the Colo-
rado-Utah area.

A second tour is set for July, with the exact
departure date to be chosen later. It’s a two-
week tour to the Far East, including stops in
Singapore, Hong Kong and Bali. It is possible
that the Oklahoma Bar Association will co-
sponsor this tour with the OSMA.

The third tour for 1976 will be a two- week
air-sea cruise of the Mediterranean on the new
ship "Dafphne.” The OSMA has asked for an
October departure on this trip, but on a date
that will not conflict with the OU-Texas foot-
ball weekend. Joining the OSMA as co-spon-
sors on this trip will be the Michigan Medical
Society, the Sedgwick County Medical Society
(Kansas) and the Alumni Association of the
University of Arizona.

Additional information on each of the three
tours will be distributed to all OSMA members
several months before each departure.

The first tour, the Mayan Adventure, will be
a nine-day, eight-night, air-land tour of Cen-
tral America. Price will be $649 per person.

Travelers will depart Oklahoma City and
will fly directly to San Salvador and will spend
four days in the beautiful Hotel Camino Real.
For sun worshipers the beach and the surf on
the Pacific are hard to beat, but the hotel also
has an inviting swimming pool with flower-
decked patio. For the more adventuresome,
there will be visits to the Mayan Ruins of the
ancient city of Tazumal, a view of the volcanic
Izalco and perhaps a visit to the beautiful
paradise of quiet pools and exotic flowers, Los
Charros.

From San Salvador it’s only a short flight to
Guatemala City for four more days in another
beautiful hotel by the same name, Hotel

368

Camino Real. The hotel features a beautiful
swimming pool, an elegant la Ronda supper
club, the El Jaguar Bar and one of the best
botiques in the city. Tennis courts and a golf
course are nearby.

From Guatemala City, there is an optional
excursion to the 9th Century Mayan Ceremon-
ial Center of Tikal. Here the traveler will see
the ornate Temple of the Masks and the impos-
ing 21 story high Temple of the Giant Jaguar.

No one should miss a side trip to Antigua,
the colonial capitol of Guatemala. The city is a
monument to the past with fountains, villas,
and ancient cypress trees. A visit to the city is
a return to the 17th Century.

Another optional side tour, and one not to
miss, is a trip to the Spanish village of
Chichicastenango. On market day the pure
blooded Quiche Indians, direct descendents of
the Mayan’s, come from the surrounding hills
to barter and to worship both Christian and
Pagan Gods at the Church of Santo Tomas.

A full schedule of scientific courses being ar-
ranged for the Mayan Adventure.

Additional information on the adventure
will be forwarded to all OSMA members in the
near future. □

Immunization Action Month Set
For October

October is Immunization Action Month in
Oklahoma. Purpose of the special month is to
locate and immunize susceptible persons to
childhood diseases such as measles, rubella,
polio, diphtheria, tetanus, and pertussis.

A major promotional campaign is being
scheduled for October by the Oklahoma State
Department of Health and the Center for Dis-
ease Control.

Physicians throughout the state will be
encouraged to initiate a working audit of pa-
tients immunization records. Each time a rec-
ord is pulled, for any reason, the vaccination
status of the patient should be determined. A
special notation should be made if it is deter-
mined that the patient is susceptible to the dis-
eases in question.

At the same time, parents will be encour-
aged to perform their own vaccination audit of
their children. If there are any questions par-
ents will be asked to contact their family
physicians or public health officers for aid.

During the past ten years health officers
have noted that the immunization level has
been decreasing slowly, although it fluctuates

Oklahoma State Medical Association

from year to year. As an example, in 1965, 84
percent of Oklahoma’s pre-school children had
been vaccinated for polio. Ten years later, only
71 percent had been so vaccinated. During the
same period, the percentage vaccinated for
measles dropped to 70 percent, for rubella to 77
percent, for mumps to 35 percent, and for
diphtheria, tetanus, and pertussis to 76 per-
cent.

The result of this drop in immunization level
is that these preventable diseases, once
thought to have been brought under control,
are now reappearing. The greatest danger is to
pre-school children. Oklahoma, like many
other states, has a law that says that a child
may not enter school in this state for the first
time unless he has received certain immuniza-
tions. Many parents wait until the child is
ready to enter school before either complete, or
in some instances, even start, the child’s
immunization program.

Public health experts have speculated that
the reason so many children go unvaccinated is
that people no longer fear the diseases, they
consider them to be a thing of the past. It is
estimated that nearly 40,000 Oklahoma chil-
dren between the ages of one and four years are
either unimmunized or inadequately im-

munized against the so-called childhood dis-
eases.

The immunization levels differ from county
to county in Oklahoma. Using polio as an ex-
ample, the percent of preschool children fully
protected against polio ranges from only 50.4
percent in Adair County to 84.1 percent in
Texas County. Measles immunization is lowest
in Delaware County with a 54.9 percent level
and highest in Seminole County with 87.2 per-
cent.

Immunization levels for rubella are the
highest everywhere with a statewide average
of 76.9 percent. Only one county, Cherokee,
has an immunization level less than 60 percent
for rubella, with 59.6 percent. The highest
rubella immunization level is in Love County
with 87.4 percent of preschool children fully
protected.

Immunization Action Month is now in its
third year. It is a cooperative effort sponsored
by the Oklahoma State Health Department,
the Oklahoma State Medical Association, gov-
ernment, industry and volunteer organiza-
tions. Although last year’s immunization level
increase was small, it did mark the beginning
of an upward trend. □

HEALTH CARE MANAGEMENT

MASSES OF PAPERWORK AND SLOW RECEIVABLES
. . . these two enemies are overwhelming todays Medica
Office! How to deal with these two is the “number one
business problem” for many doctors.

HCM's system is simple, easy to learn, requires no
special equipment, is flexible, and can follow along the
lines of your present business office procedures.

For further information, contact:
Gene Highfill

Academy Computing Corporation
3535 NW 58th — Suite 102
Oklahoma City, Oklahoma 73112
405/947-7746

Journal / September 1975 / Volume 68

369

news

Inter-American Symposium
On Internal Medicine
Will Convene In Mexico

The Department of Medicine, University of
Oklahoma Health Sciences Center in associa-
tion with the National Academy of Medicine of
Mexico will sponsor the first annual Inter-
American Symposium on Internal Medicine in
Mexico City next January. The meeting will
convene at the Centro Medico of the Institute
Mexicano Del Seguro Social, January 12th to
15th, 1976.

Theme for the course will be "What’s New In
Diagnosis and Therapy” offering a thorough
update on trends in internal medicine. Subject
material will feature discussion in gastro-
enterology, cardiovascular, renal, pulmonary,
hematology-oncology, endocrinology and infec-
tious diseases. The Inter-American nature is
realized by the participation of well-known and
respected educators from Mexico and Canada,
complementing a superb faculty from the Uni-
versity of Oklahoma.

Group air fares will be available from a

choice of US cities, as well as a package of fine
hotel accommodations, sightseeing and meals
during the stay in Mexico City. Plans are being
made to bring the participants and their wives
to Mexico on Saturday, January 10th for leis-
ure time before the symposium activities be-
gin. For those wishing to stay on for a few days
after the meeting, there will be a choice of
three post-symposium tours covering various
points of interest in Mexico.

Further details may be obtained by writing
James F. Hammarsten, MD, and Solomon
Papper, MD, co-directors, The University of
Oklahoma Health Sciences Center, College of
Medicine, Department of Medicine, P.O. Box
26901, Oklahoma City, Oklahoma 73190. □

ANNUAL SCIENTIFIC MEETING

of the

OKLAHOMA RHEUMATISM SOCIETY

October 11th, 1975 Shangri La Lodge

Afton, Oklahoma

Principal Guest Speaker will be Eric Hurd, MD, As-
sociate Professor of Medicine, Southwest Medical
School, Dallas, Texas. His topic will be “Extra Manifes-
tations in Rheumatic Diseases.’’

SPONSORED BYTHE OSMA

Washington National Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE
DISABILITY INCOME INSURANCE

Contact Association Counselors:

Jim Thaxton, Bill Howard or Rodman A. Frates

Administrators

720 NW 50th

PC Box 1 8593 405 842-3735 Oklahoma City 73118

370

Oklahoma State Medical Association

Oklahoma Trauma Society
Will Hold September Symposium

The Oklahoma Trauma Research Society
will present its annual symposium for
emergency medical professionals, "AREMSYS
V” in Tulsa, September 10th, 11th and 12th.
The meeting will be co-sponsored by the Okla-
homa Committee on Trauma of the American
College of Surgeons, the Oklahoma Chapter of
the American College of Emergency Physi-
cians, and the Oklahoma Chapter of the
Emergency Department Nurses Association.

The physicians’ seminar will present topics
of interest to both the rural and urban physi-
cian involved with emergency medicine on a
full or part-time basis.

The faculty of specialty physicians will pres-
ent sessions on air-way management; assess-
ment and management of the shock patient;
head, neck and spinal cord injuries; facial in-
juries; cardiac emergencies, and many other
pertinent topics.

The curriculum has been submitted for credit
to the American College of Emergency Physi-
cians, the AMA’s Physician Recognition
Award, and the American Academy of Family
Practice.

Registration for physicians is $75. For com-
plete details, contact the Oklahoma Trauma
Research Society, Suite 811, 6465 South Yale,
Tulsa 74136. □

Miscellaneous Advertisements

WELL-TRAINED INTERNAL MEDICINE
specialist needed immediately for medium-
sized Oklahoma city with outstanding hospi-
tal facilities and full range of specialty care.
Existing practice nets $60,000 a year. Contact
Key W, The Journal, Oklahoma State Medical
Association, 601 NW Expressway, Oklahoma
City, Oklahoma 73118.

TULSA, OKLAHOMA — EMERGENCY
PHYSICIAN NEEDED. Full-time or part-
time, strong emergency medicine or clinical
background very important. Major consulta-
tive hospital with large definitive care
Emergency Department provides interesting
clinical experience. Contact: Bill Dudney, MD,
Saint Francis Hospital, 6161 S. Yale, Tulsa,
Oklahoma 74136 or call 918 627-2200, ext. 611
or 612.

FAMILY PRACTICE: Attractive salary with
small group serving outpatient department in
Texas city of 156,000. 35,000 - 50,000 patients
per year. All fees paid by hospital. Send C.V.
Call collect and in confidence to Toni Clark 512
349-2651. Daniel Stern and Association,
Health Placement Services, Suite 510 GPM
South Tower, San Antonio, Texas 78216.

Journal / September 1975 / Volume 68

PHYSICIAN ASSOCIATE NEEDED in
family practice, cardiology, general surgery,
orthopedics, ophthalmology, ENT and OB-
GYN. Full associate status in as little as two
months. No buy-in required. This is perhaps
the number one practice opportunity in Ok-
lahoma. Inquiries confidential. Write or call
collect Chickasha Clinic, Inc., 224-4853, W. S.
Harrison, MD, or Jim Loy.

EMERGENCY PHYSICIANS: $50,000 -
$60,000 minimum for new grads or second
career physicians. Serve community hospitals
in Texas cities of 156,000 - 974,000. All fees
paid by hospital. Send C.V. Call collect and in
confidence to Toni Clark 512 349-2651. Daniel
Stern and Associates, Health Placement Ser-
vices, Suite 510 GPM Tower, San Antonio,
Texas 78216. □

371

auxiliary

Summer Report of the President

The 1975-76 year for the OSMA Auxiliary
began in April with a well attended post-con-
vention board meeting. In June Mrs. William
B. Renfrow, Mrs. James Haddock, Mrs. Orange
Welborn, Mrs. Joe Crosthwait. and Mrs. Ed
Calhoon, delegates, and Mrs. John McIntyre,
alternate, attended the national convention in
Atlantic City.

Doctor Malcom Todd, AMA president, gave
the keynote address. He urged auxiliary mem-
bers to become involved in an educational
campaign to gain public support for the legisla-
tion most beneficial to the health care of the
country.

Another speaker, Mary Louise Smith, Re-
publican National Committee chairman and
an auxiliary member from Iowa, spoke on the
government’s role in terms of health care and
what we, as doctors’ wives, should be doing
about it. Mrs. Smith said, "Restraint of gov-
ernment, protection of personal freedom, ad-
herence of traditional American values — all
these come as a result of raised voices. They
are a response to those who work to make the
system better,” she added, "and they are too
important to leave to someone else. Besides, if
you do not care enough about your beliefs to
stand up and fight for them . . . can you hon-
estly expect anyone else to do it for you?”

The national president, Mrs. Howard Liljes-
trand, presented Doctor John Budd, Vice-
President of the AMA Education and Research
Foundation; a check in the amount of
$1,361,564.21. Of this amount, Oklahoma had
contributed over $21,000.00. An award was
presented to the Oklahoma auxiliary for con-
tributing $16.50 per member. This is the time
to say "well done” to the almost 1,300 state
members.

Important changes were made during the
House of Delegates Meeting, including a
change of name to American Medical Associa-

372

tion Auxiliary, in keeping with the policy of
accepting both husbands and wives of physi-
cians as members. (Oklahoma has not had this
bylaws change as yet.) The house of delegates
voted a $3.00 increase in dues, bringing
national dues from $4.00 to $7.00. This will go
into effect June, 1976. Also, bylaws changed to
meet current demands of economy and pro-
gramming.

Mrs. Erie E. Wilkinson was installed as our
new national president. In her inaugural ad-
dress Mrs. Wilkinson called for unity of goals
and purpose. She said this is vital "if we, who
are concerned with medicine’s and our
husbands’ futures, are going to move forward
and face the problems and challenges before
us.” She asked for more communication of a
positive attitude. We need to be better in-
formed, she said, but better yet, we need to get
through, to our members, to other doctors’
wives, to the community.

I would be remiss if I did not mention a new
program concept from the national auxiliary
that is being implemented this year — the Pro-
ject Bank. This consists of catalogued informa-
tion, kept at national headquarters, containing
projects from county and state auxiliaries, and
programs obtained from health-related
organizations. When a county needs informa-
tion on a project or program they have access to
the "Knowhow” from all 50 states.

This plan offers a communication system
through which auxiliaries across the country
can share information on projects that have
worked successfully for other auxiliaries in
their communities.

A summer board meeting was held August
4th in the home of the president. In conjunction
with this, mini-workshops were held on Legis-
lation, AMA-ERF, Community Health and
Health Education. A workshop was also held
for the county presidents, councilors and coun-
cilors-elect on membership. Loretta Renfrow □

Oklahoma State Medical Association

Index To Advertisers

Academy Computing Corporation 369

American Medical Association ii

Baptist Medical Center xix

Beverly Hills Hospital 367

Burroughs Wellcome Co ___ xvi

Campsite, Inc xxiv

Comprehensive Consultations xx

Coyne Campbell Hospital xviii

Dunn-Reynolds Urology Center xix

Flint Laboratories ix-xii xiv-xv

C. L. Frates & Company, Inc 364

Geigy Pharmaceuticals v-vi

Georgia Academy of Family Physicians 342

Eli Lilly Company iv

Loma Linda Foods _.xxvi

Mallinckrodt, Inc xxxii-xxxiii

Massachusetts Mutual Life Insurance Co. 364

McAlester Clinic xx

McBride Clinic xxii

Medical Practices xxiv

Medicenter Psychiatric Hospital ___ 361

Oklahoma Allergy Clinic xxi

Oklahoma City Clinic xxi

The Oklahoma Plastic Surgery Center xxiii

Pharmaceutical Manufacturers

Association xxx-xxxi

Plastic & Reconstructive

Surgery Clinic, Inc xxiii

Professional Lecture Series xiii

A. H. Robins Company vii-viii

Roche Laboratories Cover, i, 344-345, xxviii-xxix

Roerig, A Division of Pfizer

Pharmaceuticals xvi-xvii, xxvii

G. D. Searle & Co._____ 342-343

Smith Kline & French 346

Southern Medical Association 362

Sugg Clinic xxii

Timberlawn xxiii

Wallace Laboratories xxiv-xxv

Washington National Insurance Co. ._ 370

Journal / September 1975 / Volume 68

of the Oklahoma State Medical Association

DEADLINES

January Issue

Editorial, Scientific, Book Reviews November 15, 1975

Advertising Copy December 12, 1975

News Copy, Miscellaneous December 10, 1975

CONTRIBUTIONS

Articles accepted for publication, including manuscripts
of annual meeting papers, are the sole property of 77m Jour-
nal and must not have been published elsewhere. Authority
for approval of all contributions rests with the Editorial
Board, and the Board reserves the right to edit any material
submitted. Manuscripts should be typewritten, double
spaced and submitted in original and one copy. Receipt of
manuscripts will be acknowledged and unused manuscripts
returned. Used manuscripts will be returned on request.
The Journal of the Oklahoma State Medical Association
is not responsible for the statements or opinions of any con-
tributor.

STYLE

Footnotes, bibliographies, and legends for illustrations
should be submitted on separate sheets, double-spaced.
Bibliographies should follow in order of: name of author,
title or article, name of periodical with volume number,
page and date of publication. These references should be
alphabetized and numbered in sequence.

ILLUSTRATIONS

Illustrations, other than the author's will not be accepted
for publication unless accompanied by written permission to
be reproduced. Illustrations should be identified by the
author's name and the figure number of the illustrations.
The illustrations should be numbered in the same order as
referred to in the body of the article. Used photographs, and
drawings will be returned after publication if requested. The
Journal will pay for necessary black and white illustrations
within reasonable limitations. The quality of drawings,
sketches, etc., must be in keeping with the quality of the
magazine.

NEWS

Members of the Oklahoma State Medical Association, the
constituent societies of the association, and all readers in
general are invited to supply news items of general interest
to the profession.

ADVERTISING

All advertising copy must be approved by the Editorial
Board before acceptance for publication. General and mis-
cellaneous advertising rates will be sent on request.

EDITING SERVICE

The Editorial Board reserves the prerogative to submit
contributions to a Medical Editing Service when warranted.
If such is felt necessary, the Editor will contact the author for
approval, informing him that there will be a modest charge
for this service.

REPRINTS

Authors will receive reprint order forms from the Trans-
cript Press, P.O. Drawer 1058, Norman, Oklahoma 73069,
prior to final publication of their articles. Other requests for
reprints must be made to the Transcript Press within 30 days
after publication.

BACK ISSUES

Microfilm copies of back issues oiThe Journal may now be
purchased from University Microfilms, 300 North Zeeb
Road, Ann Arbor, Michigan 48106.

xxx vii

the last word

Mathews is in, Weinberger is out. Caspar
Weinberger has been replaced as Secretary of
HEW by F. David Mathews. The new secretary
is a 39-year-old PhD who has served as Presi-
dent of the University of Alabama since 1969.
He was confirmed by the Senate as the new
HEW Secretary on July 22nd. In testimony on
his nomination before the Senate Labor and
Public Welfare Committee, Mathews said he is
particularly sensitive to the problems of rural
care and predicted clinics rather than hospitals
will be needed to serve remote areas.

"Trustworthiness,” physicians lead the
pack. In a survey by the Chilton Research
Service, persons were asked to rank various
professions as to trustworthiness on a scale of
one to ten. Physicians led all occupational
groups, scoring 8.2. Bankers were second with
a score of 7.9, professors scored 7.3, news re-
porters 5.8, and politicians were low on the
scale with 3.7.

Old liberals or new conservatives? One of
the questions going around Washington is just
what is happening to the old liberals. Wilbur
Cohen, former HEW Secretary, now dean of
the University of Michigan School of Educa-
tion has urged Congress to go very slowly on
acting on any national health insurance. He
testified that swift action on the issue would be
"a tragic mistake” for "so monumental an
undertaking.” Another former HEW Secre-
tary, Caspar Weinberger, revealed his more
conservative side in a California speech re-
ported on page 363 in this issue of The Journal.
Oklahoma’s share of the federal tax burden is
1.05 percent of the total. The US Chamber of
Commerce prepared an informative table
which enables taxpayers to estimate the tax
burden placed on their states by federal spend-
ing programs. The state of California is highest
with 10.80 percent of the total, New York is
second with 9.95 percent, and Wyoming is low-
est with .16 percent.

Senator James Allen, a Democrat from
Alabama, came up with the following: A re-
cent Office of Management and Budget Survey
on the number of reports required at business-

xxxviii

es — just from certain federal agencies —
shows that 2,178 different types of reports are
required and that it took business men the
equivalent of 35.6 million — that’s million —
man-hours to fill them out. And the trend is
definitely up.

Social Security Administration’s actuaries
are getting worried. They now report that
unemployment and inflation are throwing the
retirement system into deficit sooner than they
had earlier forecast. Outlays will exceed re-
ceipts this year by $2.5 billion leaving reserves
at $43.4 billion and by 1980 only $800 million
will be left in reserves — not enough to cover
one week’s benefits.

It’s not all thankless! Recently OSMA Presi-
dent Arnold G. Nelson, MD, appeared on a lo-
cal television program in Oklahoma City.
After his appearance an attorney, Toney M.
Webber, with the firm of Howell, Webber &
Sharpe, in Midwest City, took time to write
and say that although he did not get to see the
entire show, ". . .1 heard enough to make me
proud to be an Oklahoman.” Mr. Webber’s
partner, James Howell, is a State Senator from
Doctor Nelson’s district. □

AMA TULSA
REGIONAL MEETING

HILTON INN JANUARY 17th-18th, 1976

Topics to be covered are:

Basic Life Support-Cardiopulmonary
Resuscitation (CPR)

Child in the Emergency Room
Dermatology for the Non-Dermatologist
Cardiac Arrhythmias
Management of the Critically Injured
Acid-Base, Fluid and Electrolyte Balance

The charge for registrants will be $10 per
credit hour, ie, six-hour course will be $60.
Course faculty will be selected from the Okla-
homa Medical Schools in Tulsa and Oklahoma
City.

Oklahoma State Medical Association

October

1975

Vol. 68, No. 10

of the Oklahoma State Medical Association

EDITORIAL BOARD

MARK R. JOHNSON, MD
Editor-in-Chief

HARRIS D. RILEY, Jr., MD
Editor

ROBERT G. TOMPKINS, MD
Editor

CONTENTS

editorial

On the Trail of the Tricky Thyroid . . . 373

President’s Page 374

ERNEST LACHMAN, MD
Corresponding Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

OFFICERS

ARNOLD G. NELSON, MD
President

WILLIAM M. LEEBRON, MD
Vice-President

HAVEN W. MANKIN, MD
Secretary-Treasurer

scientific

Xeromammography in Private Practice, Ralf E. Taup-
mann, MD, William R. Alhracht, MD, Gary G.

Roberts, MD and James T. Boggs, MD . . 375

Cancer Of The Pancreas Mortality In Oklahoma,
(1950-1970), Elaine Zeighami, PhD and Nabih
R. Asal, PhD 379

Early Onset of Seizure Disorders And Later Per-
ceptual Problems : Case Reports, Ellidee D.

Thomas, MD ....... 387

News from the Oklahoma State Department of

Health ......... 392

STAFF

DON BLAIR
Business Manager

LOUISE MARTIN
Editorial Assistant

SUBSCRIPTION TO THE JOURNAL is in-
cluded in membership fees. Other subscrip-
tions are $6.50 per year or $1.00 per copy
with each request subject to approval of the
Editorial Board.

POSTMASTERS: Send all change of address
notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

news

Governor’s Workmen’s Compensation Commission

Begins Study ....... 394

GAO Says SRS Funds “Face Exhaustion” . . 394

Oklahoma Supreme Court Decides Optician Case . 395

Internal Medicine Course Available Via Television . 397

HSA Task Force Recommendations Nearing Comple-
tion ......... 398

Generic Drug Marketing Stymied by Federal Court 399

Oral Diabetic Drug Warning Debated . . . 399

Deaths ......... 400

Miscellaneous Advertisements ..... 401

Index To Advertisers ...... xxxiv

Woman’s Auxiliary xxxv

The Last Word ....... xxxvi

(Cover Art By William Cason )

Keflex

cephalexin

Additional information available to the profession on request.
Eli Lilly and Company
Indianapolis, Indiana 46206

Oklahoma State Medical Association

On the Trail of the Tricky Thyroid

Primary hypothyroidism is a unique endoc-
rinologic disorder. Likely it is the most often
empirically treated endocrine ailment in the
absence of bona fide evidence of dysfunction
and commonly, it is an overlooked but poten-
tially serious disease. Recent advances in lab-
oratory methodology have greatly facilitated
the recognition of hypothyroidism and auto-
mated chemical screening has uncovered here-
tofore unexpected abnormalities which can
serve as important clues in detecting decreased
thyroid function.

The advances in thyroid methodology are
principally in the ability to measure the hor-
mones involved in normal and abnormal
thyroid function by specific and sensitive assay
systems. These hormones are thyroid stimulat-
ing hormone (TSH), thyroxine (T4) and
triiodothyronine (T3). The relationship be-
tween the thyroid hormones (T3 and T4), and
TSH is an example of classic "negative feed-
back” control. Elevation of the biologically ac-
tive ("free”) thyroid hormone concentration re-
sults in less TSH secretion. Subnormal levels
of thyroid hormone are associated with ele-
vated TSH secretion.1 In addition, the T3 resin
uptake (T3RU), a test detecting the saturabil-
ity of the prime transporter of thyroxine, ie
thyroxine binding globulin (TBG), permits the
recognition of alterations in total thyroxine
concentration not due to abnormal thyroid
function per se, but due rather to changes in
the concentration of the transporting protein,
TBG. Fortunately, the mathematical integra-
tion of the degree of TBG saturation (T3RU)
and the total thyroxine (T4) correlates well
with the actual "free” thyroxine and serves as
a good index of true thyroid function. These
mathematically integrated values may be cal-
led thyroxine-resin T3 index (T3RU x T4
concentration) or "adjusted thyroxine” (T3RU
of patient/T3RU of normal x thyroxine
concentration). The information gained is the
same, but the American Thyroid Association
recommends that the former name be used.

Certainly, terms such as T7 are meaningless
jargon and should be avoided.2

Hypothyroidism may be far advanced and
obvious, or as many clinicians know, it may
also be subtle and difficult to define. Today,
however, instead of bedside cogitation and
empiric therapeutic trials, the new laboratory
methods have removed the blinders from these
subtle expressions of hypothyroidism and
allow the physician to carefully document
thyroid dysfunction. Primary thyroid hypo-
function can be detected even when the
circulating levels of thyroid hormones are
"within normal limits,” because it is the
individual’s own control mechanisms that de-
fine euthyroidism as opposed to hypothyroid-
ism. For example, a low normal thyroxine or
thyroxine-resin T3 index, if associated with
elevated TSH levels, is hypothyroidism and
should be so approached therapeutically. Addi-
tionally, the findings of an elevated TSH
concentration in the face of a definitely low
thyroxine level removes all doubt as to a cen-
tral or pituitary cause of hypothyroidism and
pinpoints the disorder to the thyroid gland it-
self.

Automated biochemical analyses of blood
specimens have identified several changes
commonly seen in hypothyroidism which may
not be widely appreciated. Certainly, eleva-
tions of cholesterol have long been associated
with hypothyroidism, but striking elevations
of serum creatine phosphokinase (CPK), SGOT
and LDH enzymes have been relatively recent-
ly noticed. The CPK determination, particular-
ly, may be dramatically elevated in
hypothyroidism and can thus serve as a clue to
the underlying disorder.3 The alterations of
SGOT and LDH are seen with less regularity.
The presence of these enzymes in the blood can
probably be traced to "leaks” in the hypothy-
roid skeletal muscle cell membrane.4 Local ex-
perience in both in- and outpatient practice is

(Continued on Page 399)

Journal / October 1975 / Volume 68

373

president's page

Professional Liability
Study Commission

The Board of Trustees of
the Oklahoma State Med-
ical Association approved
the formation of a new
committee called the "Pro-
fessional Liability Study
Commission.” The pur-
pose of this committee is to
formulate a two or three
year game plan designed
to bolster our position, and thus prevent the
favorable Oklahoma Professional Liability
situation from deteriorating.

Even though Oklahoma has the best state-
wide Insurance Program in the Nation, com-
placency will not ensure our number one posi-
tion. In fact, unless we take steps beginning
now, it is virtually assured that we cannot con-
tinue to buck an adverse national trend for any
length of time in the professional liability in-
surance field.

To successfully solve the problems that we
may be faced with in Professional Liability In-
surance, I have named a very strong Commit-
tee whose brain power is equal to the task be-
fore them. Serving on this Study Commission
are the following:

C. Alton Brown, MB, Chairman: Doctor
Brown has served as the Chairman of the
OSMA Council on Insurance for a number of
years, and therefore, I feel that he has a very
appropriate background for this Study Com-
mission.

Barton Carl, MB: Chairman of the OSMA
Legislative Committee. Doctor Carl has very
effectively served our Oklahoma Legislative
Committee for many years and is therefore es-
sential to the Study Commission.

Floyd Miller, MB: Doctor Miller is repres-
enting the American College of Physicians,
and is a Past-President of the Tulsa County
Medical Society.

Leroy Long, MB: Doctor Long is represent-
ing the American College of Surgeons.

William G. Bernhardt, MB: Doctor Bern-
hardt is representing the Oklahoma Academy

374

of Family Physicians. He has served on the
Association’s Insurance Council and the Legis-
lative Committee for several years.

Jack Spencer, MD: Doctor Spencer is rep-
resenting the Oklahoma County Medical So-
ciety.

George Kamp, MD: Doctor Kamp is repres-
enting the Tulsa County Medical Society.

Ex-Officio Members of the Study Commis-
sion will be:

Roy Lytle, Attorney: Mr. Lytle is the OSMA
General Counsel.

George Short, Attorney: Mr. Short is one of
our defense attorneys in the Oklahoma City
office.

Joe Glass, Attorney: Mr. Glass is one of our
defense attorneys in the Tulsa office.

Tom Haynes: Mr. Haynes is the able
Claims Manager of the Insurance Company of
North America.

Rod Frates: Our general insurance agent,
Mr. Frates manages what we believe to be the
best statewide insurance program in this na-
tion.

This Study Commission will, no doubt, make
many recommendations. Legislative reform
will, of course, be of primary interest; but we
should not limit our activities to that area.
Doctor Barton Carl will tell us that there are
practical political deterrents against any ex-
pectations we have that total security can be
found through legislative relief. We must pre-
vent malpractice claims from occurring with
increasing frequency, and the association has a
role to play in making its members better
clinicians and in making certain that our as-
sociation members become intimately ac-
quainted with the legal responsibilities they
have to their patients.

It seems even more important, regardless of
the malpractice consequences, that the time
has come to reassess how we treat our patients
as sensitive human beings whose lives have
been interrupted with unwanted and unex-
pected illnesses. This Study Commission will
undoubtedly want to receive testimony from
special interest groups within our own ranks
and with our various members who have ex-
pertise in the various fields of medicine. The
Commission, no doubt, will discuss our con-
cerns with lawyer groups, and certainly will
need to make contact with the leaders of the
Legislature. It will also be important to discuss
the important issues with the members of the
Executive Branch of our State Government.

(Continued on Page 395)

Oklahoma State Medical Association

scientific

Xeromammography in Private

Practice

RALF E. TAUPMANN, MD
WILLIAM R. ALBRACHT, MD
GARY G. ROBERTS, MD
JAMES T. BOGGS, MD

Xeromammography appears to offer one of the
better methods for early detection
of breast cancer.

Twelve hundred xeromammograms were
performed in a period from 1 Jan 74 to 31
Oct 74. Two months were allowed for biopsy
reports to accumulate. The following is a dis-
cussion of our experience with this number
of xerograms. The four authors had similar
special xerographic training, making term-
inology of interpretation easier to standardize
and tabulate.

Medical interest was first given the
xeroradiographic process in the mid 1950’s by
Roach and Hilliboe1 and also by Campbell et
al.2 Gould et al3 and Rusika4 explored the
xeroradiographic capabilities in the early
1960’s. The process was actively revised in the
mid 1960’s by John Wolfe5 of Detroit and John
Martin6 of Houston. This was accomplished as
a joint effort by the Xerox Corporation and the

Radiology Associates, Inc. and Baptist Medical Center, Oklahoma City

American College of Radiology Breast Cancer
Task Force.

The xerographic process utilizes a special
aluminum plate coated with a thin layer of
selenium, a semi-conductor, which is positively
charged before use. The plate is housed in a
light-tight cassette. Conventional x-ray of low
kilovoltage is used to make the exposure. A
positively charged latent image is now on the
xerographic plate. This image is then de-
veloped by exposing it to an oppositely charged
powder and transferred to a special paper for
permanent viewing and storage.

The advantages of the xerographic process
are the rapidity with which the image can be
obtained, the elimination of a dark-room, a de-
crease in the radiation exposure to the patient
and, probably most important, a tremendous
increase in fine detail, which the xerographic
process has. This has enabled the viewer to
pick up occult carcinomas more often, as well
as to appreciate subtle changes in the ductal
pattern which heretofore were less possible
with conventional x-ray techniques. Fine
tumor calcifications previously missed on con-
ventional radiographs are much more striking
on the xeroradiographs.

The standard craniocaudad, lateral and axil-
lary views were obtained and mounted in a
mirror image fashion (Figure 1) and then
compared for changes in ductal patterns, skin
thickening, tumor calcifications, soft tissue
masses with indistinct borders, or masses that
have no obvious "mates” on the opposite image.
Attention also was paid to changes in venous-
diameter ratio.7 On many occasions, these
xeroradiographs were read by more than one
radiologist.

Journal / October 1975 / Volume 68

375

Xeromammography / TAUPMANN

Figure 1: Standard Cranio-caudad view mounted
in "mirror image” fashion. This facilitates compari-
son of areas of interest.

DISCUSSION

Twelve hundred xeroradiographs were
performed in the previously mentioned period
of time. Data collected, such as age, parity,
history of previous cancer in the patient,
and mammary cancer on the maternal side,
were recorded. Previous history of breast
exam, such as x-ray mammograms,

eromammograms or thermograms, was also
recorded. Prior biopsies were drawn on a breast
diagram. (Table 1) Two months were allowed
for as many biopsies as possible to be per-
formed and for the pathologic data to accumu-
late. Of the 1,200 exams, 146 biopsies were per-
formed. Of these 146 biopsies, 124 specimens
were from benign tissue; 22 specimens were
from malignant tissue. (See diagram for age
distribution on Table 2) These statistics corre-
late relatively well with those of Martin8 and
Wolfe9 but fall below those of Frankel.10

Of the 22 malignancies there were two origi-
nally interpreted as benign tumors. On one of
these "false negatives,” a mass was described,
but because of its smooth borders it was called
probably benign. This turned out be a "knobby”
carcinoma. The other was missed completely.
Ninety-three per cent were correctly diagnosed
and 10% of these were occult. We deemed a
lesion occult when it was found de-novo, in a
location where the referring physician did not
palpate it or in the opposite breast. It is of note
that two of the malignancies were in patients
who had metastases from sites other than the
breast. One was carcinoma of the lung with
metastasis to a high lymph node in the breast;
the other was an adenocarcinoma from an un-
determined site with the patient also having
subcutaneous nodules on her back below the
scapular margin and several lesions within
both lung fields.

Of the 124 biopsied benign tumors, 106 were
diagnosed correctly and 18 "false positives”
were diagnosed. The 18 false positives fell into

PHYSICAL EXAMINATION: DIAGRAM MASSES, PREVIOUS SURGERY SITES, SKIN AND NIPPLE ABNORMALITIES,

MOLES, AND WARTS.

376

Oklahoma State Medical Association

Breakdown by age of 146 Biopsies

Age

and

below

30-40

40-50

50-60 60-70

70-80

and

above

Total

Benign

27 12

124

Malignant

3 4

TABLE 2

Total 146

a category which were called suspicious on the
xerogram report. Either biopsy or re-
examination in three to six months was sug-
gested. Thirty-six biopsies were performed on
the basis of a diagnosis of a benign tumor, a
suspicious mass on palpation being the prob-
able criterion. These patients were all above 35
years of age.

The authors tried to adhere to three main
diagnoses. If the lesions had characteristics of
malignancies and were well-documented they
were called malignant and biopsy was strongly
recommended. A second category, rather small
in number, showed a suspicious "mass” effect
which had certain features suggesting car-
cinoma; biopsy or re-study in three to six
months was suggested. Lesions of the third
category were called benign. As with all x-ray
and xerographic examinations, the history and
the location of palpated masses were extremely
important in the classification of lesions.

From our breast questionnaire, it is interest-
ing to note that 467 women reported finding a
lump on self-examination and sought further

Figure 2: A. Colloid Carcinoma of Breast (closed
arrow). Mole on skin (open arrow). Note this could
easily be mistaken for a tumor.

B. Infiltrating duct carcinoma. Note fine sand-like
calcifications (long arrow).

C. Note rather marked skin thickening (open
arrow). Patient has infiltrating duct carcinoma
(closed arrows).

Journal / October 1975 / Volume 68

help from their physician. Four hundred
seventy-four women had lumps palpated by
their physicians on routine physical ex-
aminations. Specifically, 14 patients had a
positive or suspicious thermogram. Seventy-
five patients were follow-up patients for
routine xeromammograms following breast
cancer surgery on the opposite breast. Seven
patients had "baseline” xeromammograms
prior to augmentation mammoplasty. A small
number of patients were concerned and just
wanted the study performed. The remaining
163 patients gave no particular reason that
could be ascertained from our questionnaire for
having the exam. Some patients, although
urged to fill out the questionnaire completely,
chose not to do so.

Another interesting fact is the time which
had elapsed between the discovery of the lump

Since his graduation from the University of
Texas Medical Branch at Galveston, Ralf E.
Taupmann, MD, has been certified by the
American Board of Radiology . He is in private
practice in Oklahoma City and is a member of
the Radiologic Society of North America, the
American College of Radiology , and the Ameri-
can Thermographic Society.

William R. Albracht, MD, graduated from
the Southwestern Medical School of the Univer-
sity of Texas, Dallas, and has been certified by
the American Board of Radiology . He is a
member of the American College of Radiology .

A graduate of the University of Louisville
School of Medicine, Gary G. Roberts, MD, has
been certified by the American Board of Radiol-
ogy. He is affiliated with the American College
of Radiology .

A University of Oklahoma College of Medi-
cine graduate, James T. Boggs, MD, is certified
by the American Board of Radiology. Among
his medical affiliations are the American Col-
lege of Radiology , the Oklahoma State Radiol-
ogy Society and the Greater Oklahoma City
Radiology Society.

377

Xeromammography / TAUPMANN

Figure 3: Patient shows a large intra ductal CA
(see open arrow) with calcifications scattered
throughout.

or the suspicious lesion and medical help was
sought or a xeromammogram was requested.
This varied from a few days or weeks to several
months. Seven patients waited a year or more
until seeking further medical attention for
their "breast lump” Curiously enough, three of
these had carcinoma.

We also found it important to have a compe-
tent technologist performing the actual xero-
graphic examination. Proper positioning is a
must for good reproduction of the bilateral
"mirror” image. Radiographic settings (ie KVP
and MAS) also are critical, and a well-trained
technician can adjust these according to the
size and consistency of the breast of the pa-
tient. The appropriate adjustment can be made
quickly after viewing the first xerographic
image.

Mention also should be made that in our ex-
perience certain lesions or masses palpated by
the referring clinician sometimes were not im-
aged on the xeroradiographs, and conversely,
imaged masses sometimes could not be pal-
pated by the referring physicians, even though
these appeared quite large (2-3cm) on the
xerogram.

In our experience we have also found that
cooperation among the referring physician, the
radiologist and the pathologist is vital because

378

smaller tumors are now being detected by
xeromammography. This makes sectioning
and localization of these tumors more difficult
for the pathologist. Specimen xeroradiography
has been extremely helpful in localizing these
small tumors for frozen-sectioning as well as
for the preparation of permanent slides. This is
done with relative ease while the patient is
still under anesthesia, thus saving the patient
a possible second trip to the operating room
and a second anesthetic.

CONCLUSION

It appears that xeromammography has defi-
nitely established its place in the detection and
diagnosis of lesions of the breast. This is not to
suggest that a thorough manual examination
should be omitted, but should be supplemented
with xerograms. Patients in high-risk groups
and patients with previous mastectomies espe-
cially benefit from periodic examinations. The
advantages over conventional x-ray examina-
tions are evident. Ten per cent of the malig-
nancies in our series biopsied were occult, and
the breakdown of our statistics correlates fairly
well with those of other authors although our
series was not as large as some.

AC KNOWLE DGME NT

The authors wish to thank the Departments
of Pathology of Baptist Medical Center and
Deaconess Hospital for their splendid coopera-
tion.

Special thanks also go to our tireless tech-
nicians and secretaries for help with the
xeroradiographs and compilation of statistics
as well as typing of the manuscript.

REFERENCES

1. Roach, J. F., and Hilleboe, H. E.: Xeroradiography. Am. J. Roentgenol,
73:5-9, Jan. 1955.

2. Campbell, et al: Xeroroentgenography: Evaluation of Its Uses in Disease
of Bones and Joints of the Extremities. J. Bone & Joint Surg., 41A:271-277,
March 1959.

3. Gould H. R., Ruzicka, F. F., Jr. Sanchez, Ubeda R., and Perez, J.:
Xeroradiography of the Breast. Am. J. Roentgenol, 84:220;223, Aug. 1960.

4. Ruzicka, F. F., Kaufman, L., Shapiro, G., Perez, J. and Grossi, C. F.:
Xeromammography and Film Mammography-Comparative Study of Radiol-
ogy, 85:260-269, 1975.

5. Wolfe, J. N.: Xerography of Breast. Radiology, 91:231-240, 1968.

6. Martin, John E.: Personal Communication.

7. Dodd, G. D. and Wallace, J. D.: The Venous Diameter Ratio in Radio-
graphic Diagnosis of Breast Cancer. Radiology, 90:900-904, 1968.

8. Martin, J. E.: Xeromammography- An Improved Diagnostic Method: A
Review of 250 Biopsied Cases. Amer. J. Roentgen, 97:90-96, 1973.

9. Wolfe, J. N.; Xeroradiography of the Breast. Read before the 7th Annual
Cancer Conference Proceedings. 1973.

10. Frank, G. and Rosenfeld, D. D.: Breast Xeroradiography: Analysis of our
First 17 Months. Ann. Surg., 178:676-679, 1973.

Suite 204, 3141 NW Expressway, Oklahoma City,
Oklahoma 73112

Oklahoma State Medical Association

Cancer Of The Pancreas Mortality
In Oklahoma, (1950-1970)

ELAINE ZEIGHAMI, PhD
NABIH R. ASAL, PhD

A steady rise in cancer of pancreas
mortality was found in Oklahomp. Mortality
was also found to be higher in rural areas
than metropolitan. This disease is the fourth
leading cause of cancer death in the US with
a five-year survival rate less than two percent.

There has been very little published in the
area of the epidemiology of cancer of the pan-
creas. The available information indicates that
cancer originating in the pancreas (Interna-
tional Statistical Classification of Disease
[ISC] 157) is the fourth leading cause of can-
cer death in the United States. The incidence
and mortality from the disease have been rising
steadily over the last twenty years.2 The sur-
vival rate for pancreatic cancer is very low,
with the survival rate for five years being
about two percent. This figure has not changed

From the Department of Biostatistics and Epidemiology, Division of Public
Health, College of Health, The University of Oklahoma Health Sciences Cen-
ter, Oklahoma City, Oklahoma

Journal / October 1975 / Volume 68

greatly over the last twenty years. In the
1950’s, mortality was 76% of reported in-
cidence for whites and 50% for non-whites.
Therefore it would appear that there was
considerable under-reporting of mortality
in the past, and part of the current rise in
the mortality at this site is probably attribut-
able to better mortality reporting. Cancer of
the pancreas is uniformly higher in males than
in females both in the white and non-white
populations. This relationship has remained
reasonably stable over the last twenty years.
Male rates also are higher in international
data for almost all countries reported by Segi.4

According to Segi,4 non-white rates in the
United States are the highest in the twenty-
four countries for which he reports mortality.
The age-adjusted death rate in 1964 for non-
white males was 9.8 per 100,000 and for non-
white females was 5.9 per 100,000. Japan and
Italy have the lowest rates for the twenty-four
countries.

Men working in coke and gas plants, com-
panies manufacturing /Lnaphthylamine and
benzidine also have shown high death rates
from pancreatic cancer. A study by Li1 of mem-
bers of the American Chemical Society showed
an excess of deaths from pancreatic cancer. Al-
coholics and heavy drinkers also have been
suspected of having high death rates from the
disease.3.

Two reports published by Wynder et al.5'6

379

Mortality / ZEIGHAMI, et al

Table I

Annual Age-Adjusted Death Rates
per 100,000 Population, Cancer of the Pancreas,
Oklahoma, 1950-1970

Year

Rate

Year

Rate

1950

5.3

1961

7.8

1951

6.6

1962

8.7

1952

7.1

1963

7.5

1953

6.0

1964

6.9

1954

7.0

1965

7.7

1956

7.9

1966

8.8

1957

7.5

1967

8.7

1958

6.6

1968

8.6

1959

6.6

1969

9.4

1960

9.6

1970

9.0

over the last twenty years with respect to sev-
eral epidemiologic features.

METHODS

In the present study, the death certificate
data from 1950-1970 except 1955 for all deaths
in Oklahoma due to cancer of the pancreas was
obtained from the State Department of Health.
The year 1955 was missing due to the damage
of a tape the data was stored on. Information
for the general population was obtained from
the United States Census reports. The usual
epidemiologic and statistical analyses for mor-
tality data were utilized. All adjusted rates
were age-adjusted using the 1960 white male
Oklahoma population as the standard.

RESULTS AND DISCUSSION

showed an association of pancreatic cancer
with cigarette smoking in males and a signifi-
cant relationship to early onset of diabetes and
history of cholecystectomy in females. The au-
thors suggested that bile containing carcino-
gens from tobacco or occupational environ-
ment, and possibly diet, might cause cancer on
reflux into the pancreatic duct.

The purpose of this report is to analyze mor-
tality from cancer of the pancreas in Oklahoma

The mortality rates obtained for the total
population for each year in the study are shown
in Table I. The age-adjusted death rates for
Oklahoma reflect the general upward trend
seen in national data, although the rise is not
dramatic, and may be explainable for the most
part by better diagnosis and improving
certification and selection of underlying cause
of death.

Table II presents the age-specific rates ob-

Table II

Age-Specific Death Rates per 100,000 Population, Cancer of the Pancreas,

Oklahoma, 1950-1970

Year

0-5

5-14

15-24

25-34

35-44

45-54

55-64

65-74

75+

1950

.00

.64

.67

5.19

12.38

22.24

55.69

1951

.42

.00

.32

.33

6.39

17.76

37.07

48.55

1952

.00

.32

2.67

7.99

16.20

29.66

65.69

1953

.00

.26

.31

1.00

5.59

16.20

25.21

57.12

1954

.42

.00

.32

1.00

3.78

17.77

32.62

55.69

1955

—

1956

.00

.30

.00

1.08

9.07

21.44

41.89

56.91

1957

.00

1.04

2.41

4.91

20.49

41.89

52.27

1958

.00

.70

2.06

4.91

16.20

35.35

53.43

1959

.00

2.40

4.91

16.20

35.35

54.59

1960

.00

1.04

1.37

6.05

24.78

45.82

94.08

1961

.41

.21

.00

.38

1.05

3.98

15.09

45.83

74.38

1962

.00

2.11

5.79

26.18

42.81

72.37

1963

.41

.00

.70

6.51

22.19

34.37

65.34

1964

.00

.38

1.41

6.87

21.71

26.18

60.31

1965

.00

.38

.70

6.51

21.30

39.20

64.33

1966

.00

.34

3.17

5.72

21.09

46.71

75.97

1967

.00

.33

.70

8.22

25.15

39.39

76.86

1968

.00

2.46

7.51

20.28

42.21

77.56

1969

.00

.34

1.41

8.58

23.93

45.58

84.01

1970

.00

2.11

7.51

27.18

38.83

80.44

380

Oklahoma State Medical Association

I *

Table III

Average Annual Sex-Specific Rates
per 100,000 and Sex Ratios,
Cancer of the Pancreas
Oklahoma, 1950-1970

Period

Male Rate

Female Rate

Sex Ratio

1950-1954

7.9

5.1

1.6

1956-1960

10.0

5.7

1.8

1961-1965

9.9

6.0

1.7

1966-1970

11.6

6.6

1.8

tained for each year. As may be seen, the dis-
ease is one primarily of the aged population.
The average yearly and sex-specific rates and
the sex ratio for the periods 1950-54,
1956-1960, 1961-1965, and 1966-1970 are
shown in Table III. The male rates are uni-
formly higher than the female rates, with the
sex ratio remaining fairly constant at about
1.65. This is again reflective of the national
statistics for this site.

Figure 1 shows the age-specific sex ratio for
the years 1965-1970. It appears that the sex
ratio is highest in the middle years. This is
again reflective of the national data, which
also show the sex ratio to be highest in the
middle years and declining in the very old.

A comparison of the white and non-white
rates for the four periods is shown in Table IV.
The non-white rates are not as high as those
for the national population. However, the
non-white population in Oklahoma includes a
considerable Indian population, which would
not be a factor in the United States data. Hence
the non-white population in Oklahoma may
not be strictly comparable to the non-white
population of the United States. It would be
worthy of note that the non-white rate has
risen faster in the last twenty years than the

Table IV

Average Annual Race-Specific Rates per 100,000,
Cancer of the Pancreas,

Oklahoma, 1950-1970

Year

White Rates

Non-White Rates

1950-1954

6.6

4.9

1956-1960

7.8

6.5

1961-1965

7.6

8.6

1966-1970

8.9

8.1

Figure 1. Age-Specific Sex-Ratios for Pancreatic
Cancer Mortality, Oklahoma, 1966-1970.

white rate. It is possible that there may be con-
siderable under-reporting of mortality in the
non-white population in Oklahoma.

Lastly, it was desired to analyze the data by
county to examine any possible urban-rural
differences and to see if geographic trends
exist. A mortality ratio for each of the
seventy-seven counties in Oklahoma was cal-
culated for 1965-1970, using the 1970 popula-
tion as the denominator population. The ex-
pected number of deaths was calculated by tak-
ing the rate for the entire state and multiply-
ing by the population of the county. The mor-
tality ration was then calculated as ob-
served/expected multiplied by 100. (Figure
2)

The two metropolitan counties both have
mortality ratios considerably less than 100. In

Elaine Zeighami, PhD, is Assistant Professor
in the Department of Community Medicine,
School of Medicine, Pahlavi University, Shiraz,
Iran.

A 1969 graduate of the University of Ok-
lahoma, Nahih R. Asal, PhD, is presently Pro-
fessor of Biostatistics and Epidemiology, Divi-
sion of Public Health, College of Health, Uni-
versity of Oklahoma Health Sciences Center. He
is a member of the Society for Epidemiologic
Research and the American Public Health As-
sociation.

Journal / October 1975 / Volume 68

381

Mortality / ZEIGHAMI, et al

Figure 2. Pancreatic Cancer Standard Mortality
Ratios By County, 1966-1970.

general, the trend is for the rural counties to
have high mortality ratios and the urban coun-
ties to have low mortality ratios. However, the
mortality ratio presented here is not adjusted
for age, and since pancreatic cancer is more
prevalent in the older age groups, this may ac-
count for most or all the observed differences.

SUMMARY

The mortality data for the state of Oklahoma
was analyzed for the site cancer of the pancreas
for the years 1950-1970, excluding 1955. It was
found that the mortality rate has been rising
slightly over the last twenty years. The rates
for males are higher than those for females,
with the sex ratio highest in the middle ages.
The rates for non-whites were not observed to
be higher than those for the white population,
in contrast to national mortality data. It was
thought that this may be due partly to the dif-
ferent nature of the non-white population in
Oklahoma than the national population. The
mortality ratios by county for the years
1966-1970 were calculated. The mortality
ratios in general were higher in the rural areas
than in the metropolitan areas.

REFERENCES

1. Burch, G. E. and Ansari, A.: Chronic Alcoholism and Carcinoma of the
Pancreas. Arch. Intern. Med. 122:273-275 (1968).

2. Levin, David L. and Roger R. Connelly : Cancer of the Pancreas, Available
Epidemiologic Information and its Implications. Cancer 31:1231-1236 (1973).

3. Li, F. P., Fraumeni, J. F., Jr., Mantel, N., and Miller, R. W.: Cancer
Mortality Among Chemists. J. Natl. Cancer Inst. 43:1159-1164 (1969).

4. Segi, M.: Cancer Mortality for Selected Sites in 24 Countries, No. 5
(1964-1965). Sendai, Japan, Tohoku University School of Medicine (1969).

5. Wynder, E. L., Mabuchi, Kiyohiko, Maruchi, Nobuhiro, and Fortner,
Joseph.: Epidemiology of Cancer of the Pancreas. Journal of the National
Cancer Institute 50:645-667 (1973).

6. Wynder, E. L., Mabuchi, Kiyohiko, Maruchi, Nobuhiro, and Fortner,
Joseph.: A Case-Control Study of Cancer of the Pancreas. Cancer 31:641-648
(1973).

P.O. Box 26901, Oklahoma City, Oklahoma 73190

IMPORTANT INFORMATION: This is a Sched-
ule V substance by Federal law; diphenoxylate
HCI is chemically related to meperidine. In
case of overdosage or individual hypersensi-
tivity, reactions similar to those after meperi-
dine or morphine overdosage may occur;
treatment is similar to that for meperidine or
morphine intoxication (prolonged and careful
monitoring). Respiratory depression may recur
in spite of an initial response to Nalline® (nal-
orphine HCI) or Narcan ® (naloxone HCI) or
may be evidenced as late as 30 hours after in-
gestion. LOMOTIL IS NOT AN INNOCUOUS
DRUG AND DOSAGE RECOMMENDATIONS
SHOULD BE STRICTLY ADHERED TO, ESPE-
CIALLY IN CHILDREN. THIS MEDICATION
SHOULD BE KEPT OUT OF REACH OF
CHILDREN.

Indications: Lomotil is effective as adjunctive ther-
apy in the management of diarrhea.

Contraindications: In children less than 2 years,
due to the decreased safety margin in younger age
groups, and in patients who are jaundiced or hyper-
sensitive to diphenoxylate HCI or atropine.

Warnings: Use with special caution in young chil-
dren, because of variable response, and with extreme
caution in patients with cirrhosis and other ad-
vanced hepatic disease or abnormal liver function
tests, because of possible hepatic coma. Diphenoxy-
late HCI may potentiate the action of barbiturates,
tranquilizers and alcohol. In theory, the concurrent
use with monoamine oxidase inhibitors could pre-
cipitate hypertensive crisis. In severe dehydration
or electrolyte imbalance, withhold Lomotil until cor-
rective therapy has been initiated.

Precautions: Addiction (dependency) to diphenoxy-
late HCI is theoretically possible at high dosage. Do
not exceed recommended dosages. Administer with
caution to patients receiving addicting drugs or
known to be addiction prone or having a history of
drug abuse. The subtherapeutic amount of atropine
is added to discourage deliberate overdosage;
strictly observe contraindications, warnings and pre-
cautions for atropine; use with caution in children
since signs of atropinism may occur even with the
recommended dosage. Use with care in patients with
acute ulcerative colitis and discontinue use if ab-
dominal distention or other symptoms develop.

Adverse reactions: Atropine effects include dryness
of skin and mucous membranes, flushing, hyper-
thermia, tachycardia and urinary retention. Other
side effects with Lomotil include nausea, sedation,
vomiting, swelling of the gums, abdominal discom-
fort, respiratory depression, numbness of the ex-
tremities, headache, dizziness, depression, malaise,
drowsiness, coma, lethargy, anorexia, restlessness,
euphoria, pruritus, angioneurotic edema, giant urti-
caria, paralytic ileus, and toxic megacolon.

Dosage and administration: Lomotil Is contraindi-
cated in children less than 2 years old. Use only
Lomotil liquid for children 2to 12years old. Forages
2 to 5 years, 4 ml. (2 mg.) t.i.d.; 5 to 8 years, 4 ml.
(2 mg.) q.i.d.; 8 to 12 years, 4 ml. (2 mg.) 5 times
daily; adults, two tablets (5 mg.) t.i.d. to two tablets
(5 mg.) q.i.d. or two regular teaspoonfuls (10 ml.,
5 mg.) q.i.d. Maintenance dosage may be as low as
one fourth of the initial dosage. Make downward
dosage adjustment as soon as initial symptoms are
controlled.

Overdosage: Keep the medication out of the reach
of children since accidental overdosage may cause
severe, even fatal, respiratory depression. Signs of
overdosage include flushing, hyperthermia, tachy-
cardia, lethargy or coma, hypotonic reflexes, nystag-
mus, pinpoint pupils and respiratory depression
which may occur 12 to 30 hours after overdose. Evac-
uate stomach by lavage, establish a patent airway
and, when necessary, assist respiration mechani-
cally. A narcotic antagonist may be used in severe
respiratory depression. Observation should extend
over at least 48 hours.

Dosage forms: Tablets, 2.5 mg. of diphenoxylate HCI
with 0.025 mg. of atropine sulfate. Liquid, 2.5 mg. of
diphenoxylate HCI and 0.025 mg. of atropine sulfate
per 5 ml. A plastic dropper calibrated in increments
of Yi ml. (total capacity, 2 ml.) accompanies each
2-oz. bottle of Lomotil liquid.

Searle & Co.

San Juan, Puerto Rico 00936

Address medical inquiries to:

G. D. Searle & Co.

Medical Department, Box 5110,

Chicago, Illinois 60680 455

SEARLE

382

Oklahoma State Medical Association

Early Onset of Seizure Disorders
And Later Perceptual Problems:

Case Reports

ELLIDEE D. THOMAS, MD

The sole finding of early onset of seizures
may serve to alert the physician that
perceptual problems could also be present.

Appropriate testing should be done prior to

school entrance.

Poor coordination, directionality-laterality
difficulty, or choreoathetosis are commonly de-
scribed in children with perceptual
problems.1’2 Absence of these soft neurological
findings does not rule out the possibility of a
learning disorder, however, and physicians
must be aware of other indicators. This paper
reports six cases in which early onset of seiz-
ures was associated with later perceptual prob-
lems.

Four boys and two girls were classified as
being at risk of having perceptual problems be-
cause of having had seizures during the first 18
months of life. The type of seizure as well as
the electroencephalographic abnormality var-
ied. (Table 1) The family was advised on the

From the Department of Pediatrics and the Child Study Center, Children’s
.Memorial Hospital, University of Oklahoma Health Sciences Center, and the
Oklahoma Department of Institutions, Social and Rehabilitative Services,
Oklahoma City, Oklahoma

Journal / October 1975 / Volume 68

initial visit to this examiner that the child
should be tested for perceptual problems no
later than during the kindergarten year. The
test battery included the Wechsler Intelligence
Scale for Children (WISC) or the Wechsler Pre-
school and Primary Scale of Intelligence
(WPPSI), Bender-Gestalt, Frostig Develop-
mental Test of Visual Perception (Frostig), Il-
linois Test of Psycholinguistic Ability (ITPA),
and the Wide Range Achievement Test
(WRAT). Table II summarizes the test results.

CASE REPORTS

Case I. A white female infant was the prod-
uct of a third pregnancy. The mother had two
febrile illnesses in the first and third trimes-
ters with no specific diagnosis being made in
either case. The baby was delivered with rota-
tion from right occiput posterior position to oc-
ciput anterior after five hours of labor. Birth
weight was 3.6 kg (8 lbs 1 oz); neonatal period
was normal. She was seen initially by another
pediatric neurologist at 10 weeks of age be-
cause of tremulousness, irritability, and stif-
fening. Examination showed only probably in-
creased muscle tone in the upper extremities.
Episodes of stiffening and jerking were seen
and were thought to be myoclonic seizures.
Mephobarbital and pyridoxine therapy was
started.

When first seen by this examiner, the pa-
tient at 23 months of age was seizure-free, hav-

387

Disorders / THOMAS

ing become controlled soon after beginning
medication. Growth and developmental mile-
stones were normal, and no neurological deficit
was found. EEGs continued to show seizure
discharge until six years of age, and mepho-
barbital therapy was continued until then. She
has remained symptom-free without medica-
tion, and continued follow-up showed no
neurological problems.

The patient’s overall intellectual ability was
in the bright-normal to superior range when
tested at five years, four months. Isolated defi-
cits in visual association and visual-motor per-
formance were found. The family chose to have
the child tutored for a short time although they
had been advised that she would probably do
well at school in spite of these rather mild, well
circumscribed difficulties. She has completed
second grade with excellent performance and a
happy school experience to date.

Case 2. A white male infant, the product of a
second pregnancy, was born 2% months prema-
turely weighing 1.4 kg (3 lb.). The mother had
no specific problems during pregnancy except
for mild spotting each month but she did not
feel well the entire time. Labor and delivery
were uncomplicated. The baby remained in the
nursery until 10 weeks of age. Cyanotic spells
appearing at two weeks of age were first

thought to be of cardiac origin, but were later
identified as seizures. Phenobarbital therapy
provided good control, and there were no
further seizures.

The patient’s developmental milestones
were normal and he had no neurological deficit
when he was seen at 14 months of age by this
examiner.

The EEG was abnormal with both simple
spike discharges and 14/sec and 6/sec positive
spikes. Anticonvulsant therapy was continued
until the EEG showed no seizure discharge at
which time the patient was three years old. He
has had no further seizures.

Testing done at five years, one month showed
overall intellectual ability in the average
range with indications of higher potential in
verbal areas. Specific perceptual difficulties
were found in eye-motor coordination, form
constancy, and position-in-space perception.

Projective testing was also done with some
indicators of mild difficulties in the child’s
emotional adjustment. Specific training for the
perceptual problems was carried out. Re-
evaluation prior to his entry into the first
grade showed some perceptual problems per-
sisting. He continued to receive specific tutor-
ing and completed first grade with no aca-
demic, behavioral, or emotional problems
apparent.

Case 3. A white female infant was the prod-

TABLE I

Summary of Type Seizure and EEG Abnormality

Case #

Onset

Description of Seizure

EEG

10 weeks

Myoclonic

Mixed: Atypical spike-wave complex, random
simple spikes and 14/sec. and 6/sec. positive
spikes mainly in right hemisphere.

2 weeks

(

Tonic

Non-focal simple spikes and 14/sec. and 6/sec.
positive spikes in temporal and parietal re-
gions bilaterally

18 months

Mixed: Possible grand
mal. Petit mal, possibly
some myoclonic compon-
ents early

Initial paroxysmal slowing, sometimes bilat-
erally symmetrical and sometimes posterior
right hemisphere. Later 3/sec. spike-wave com-
plexes.

12 months

Focal: possible adversive
eye movement, loss of mus-
cle tone.

Non-focal simple spikes.

7 months

Hair pulling, irritability.

Non-focal slowing and spike discharges.

3-4 months, possi-
bly 1 month.

Head tilting, screaming,
vomiting, flushing.

Non-focal spikes.

Oklahoma State Medical Association

388

TABLE II

Summary of Psychological Test Pattern
(WISC) and Perceptual Deficits

Case #

WISC Pattern

Perceptual Deficits
(Frostig and ITPA)

Performance scores 9 points below Verbal
score.

Visual-motor performance and Visual Asso-
ciation.

Performance score 30 points below Verbal
score.

Eye-motor Coordination and Visual Asso-
ciation.

Verbal Score 5 points below Performance
score.

Visual-motor and Auditory Association
and borderline Auditory Memory.

Performance score 22 points below verbal
score.

Block Design and Coding, Visual-motor
Coordination, Position in Space, and
Visual Memory.

Verbal score 13 points below Performance
score.

Eye-motor Coordination and Figure
Ground, Auditory Memory, Auditory
Association and Auditory Reception.

Performance score 10 points below
Verbal score.

Visual Memory. Indicators, but not spe-
cific deficit, in other visual tasks.

uct of a first pregnancy. Mild first trimester
bleeding and edema, which was treated with
diuretics, were the only complications experi-
enced by the mother. Birth was possibly one
month prior to expected date; a partial septum
of the uterus was found. Presentation was dou-
ble footling breech and the baby was delivered
following 5V2 hours of labor. The cervix
clamped around the head and incision was
made and the head delivered with forceps.
Respiration was spontaneous and birth weight
was 2.7 kg (6 lb 12 oz).

The neonatal period and early infancy were
marked by the baby’s crying all the time, but
there were no other difficulties. Her first seiz-
ure occurred at 18 months and was associated
with fever. No medication was given at that
time. The first seizure without fever occurred
when she was three years and three months
old, and phenobarbital therapy was instituted.
The patient was seizure-free for about 18
months when she began to have what were
thought to be grand mal and petit mal attacks
following an influenza-like illness.

This examiner first saw her when she was 57
months old. She was receiving mephobarbital
and trimethadione, but petit mal seizures still
occurred. Developmental milestones and re-
sults of neurological examination were normal
except for the patient’s frequent spells of star-
ing. Various combinations of anti-convulsants

were tried, and good control was finally ob-
tained with diphenylhydantoin, ethosuximide,
and mephobarbital. However, because of
slight, but persistent indicators of liver dys-
function, diphenlhydantoin and ethosuximide
were reluctantly discontinued. Mephobarbital
alone has continued to give good seizure con-
trol. EEG findings have varied from asymmet-
rical slowing only on the initial record, to spike
wave on subsequent ones. EEG findings re-
main abnormal and medication has been con-
tinued.

Testing was done when the patient was six
years, two months old and reportedly having
difficulty in kindergarten. Overall intellectual
ability was average with indicators of possible
higher potential. Deficits in visual-motor areas
and auditory association were found along
with a borderline deficit in auditory memory.

Remedial educational tutoring was con-

A graduate of the University of Arkansas
School of Medicine, Ellidee D. Thomas, MD, is
presently Professor of Pediatrics at the Univer-
sity of Oklahoma Health Sciences Center and
Director of the Child Study Center. Doctor
Thomas is a member of the Child Neurology
Society, the International Child Neurology As-
sociation and the Academy of Neurology.

Journal / October 1975 / Volume 68

389

Disorders / THOMAS

tinued into the third grade. Testing done prior
to fourth grade showed that the areas of previ-
ous deficits were all now within normal range,
but the visual-motor functions remained rela-
tively low compared to other visual skills. She
did well in fourth grade work without specific
help.

Case 4. A white male infant was the product
of a normal second pregnancy. Labor lasted for
50 minutes, with the mother having received
75 mg meperidine prior to induction of general
anesthesia. Respiration was spontaneous and
the birth weight was 2.9 kg (7 lb 12 oz).
Neonatal and early infancy periods were nor-
mal.

The father has a seizure disorder which
probably started in adolescence but wasn’t
diagnosed until his late 20s. The child’s first
seizure occurred on his first birthday and was
diagnosed as a minor convulsive disorder. EEC
was interpreted as showing "evidence of seiz-
ure disorder.” Phenobarbital therapy was
started, and the patient was seizure-free for
several months except for two hard seizures
thought to be febrile convulsions.

This examiner first saw the child at four
years, two months of age. Results of develop-
mental and neurological examinations were
normal, and no deficits were found on contin-
ued follow-up examinations. EEC findings have
continued to show seizure discharge, and medi-
cation has been continued.

Psychological testing at five years, three
months showed overall intellectual functioning
within the superior range. Deficits were found
in block design, coding, visual motor coordina-
tion, visual memory, and position in space per-
ception. He was in kindergarten at the time of
testing, but achievement tests indicated skills
at first grade level in reading and arithmetic.
The child was, slow in pencil and paper tasks,
however, and educational tutoring was done
prior to first grade. He did well in first grade
work without further help, but the family was
advised to seek assistance if he began to have
problems.

Case 5. A white female infant was the prod-
uct of a second pregnancy. Edema was the only
complication of pregnancy requiring medica-
tion. There was a short period of false labor two
weeks prior to delivery. Labor lasted 3V2 hours
and respiration was spontaneous. Birth weight
was 2.7 kg (7 lb 11 oz). The baby had club feet
which were corrected with casts. Seizures were

390

thought to have begun at about seven months
of age with irritability, hyperactivity, and
later, pulling her own hair and head banging.
Phenobarbital therapy produced a decrease in
all symptoms except irritability.

She was seen by this examiner at two years,
one month of age. Except for possible slight
speech delay, results of developmental and
neurological examinations were normal and
have remained so with speech functions ap-
proaching normal. Irritability was marked.

EEG showed slowing and spike discharges.
Because of irritability, mephobarbital was
substituted for phenobarbital with fairly good
seizure control, although occasional clinical
indications of seizures have continued.
Ethosuximide was then used, and seizures
have been controlled with continued medica-
tion. Hyperactivity became a problem when
the child entered school, and was ameliorated
by administering amphetamine.

Psychological testing was done at five years,
eight months of age. Overall intellectual func-
tioning was in the low-end-of-average range,
with some indications that potential was high-
er. Deficits were found in eye-motor skills,
figure-ground perception, auditory memory,
auditory association, and auditory reception.
She was also noted to have a low frustration
tolerance.

A self-contained learning disability class
was recommended, but she was specially tu-
tored since the class was not available.

She passed first and second grades with good
school reports, but tested low on certain group
achievement tests. Further testing showed
drops in some specific areas, but these were
thought to reflect an emotional rather than a
perceptual status. She will continue to be fol-
lowed.

Case 6. A white female infant was the prod-
uct of a diabetic mother’s first pregnancy. The
mother experienced many episodes of hypo-
glycemia during pregnancy, three of which re-
quired intravenous glucose administration and
two of these episodes probably resulted in
shock prior to treatment.

Gestation was thought to be about 35 weeks.
Labor lasted one and one-half days with the
bag of waters rupturing two days before deliv-
ery. An intravenous pitocin drip did not pre-
cipitate birth, and delivery was by Cesarean
section with the mother under spinal anes-
thesia. Respiration was spontaneous and birth
weight was 3.5 kg (6 lb 4 oz).

The baby was in an incubator for four days

Oklahoma State Medical Association

during which she was jaundiced but did not
require specific treatment. Head tilting was
noted at one month, and screaming and vomit-
ing spells began two to three months later. An
EEG at 10 months showed non-focal spikes.
Diphenylhydantoin therapy was started and
all symptoms lessened.

The patient was first seen by this examiner
at 18 months of age. There were no clear de-
velopmental delays or specific neurological de-
fects, and these indicators have remained nor-
mal. The EEG was equivocal with rare spike-
like discharges in sleep only. Because of in-
complete symptom control, however, pheno-
barbital was added to the regimen and symp-
toms cleared completely. EEG at age two years
was normal, and medication was discontinued
without the patient experiencing further diffi-
culty.

Psychological testing at five years, ten
months showed overall intellectual ability in
the superior range. There were indicators of
visual-memory difficulty and suggestive low
areas in other visual tasks. Her achievement
as measured by the Wide Range Achievement
Test (WRAT) was above her kindergarten
grade-placement but somewhat below expecta-
tions for her high overall intellectual ability.
The family was advised that she would prob-
ably benefit from some specific training, al-
though in our opinion she would continue to do
well without specific help. They chose to have
her tutored. She performed well in first grade
with only minor problems in mathematics.

DISCUSSION

Within this small group, the type of
maternal/infant difficulties encountered dur-
ing pregnancy, labor, and delivery or in the
neonatal period did not appear to correlate
with the type of seizure or EEG abnormality
and the perceptual problems found in the sub-
jects. Until a larger group can be studied
(study now in progress), it seems advisable to
consider early onset of seizure disorder per se
as a likely indicator of perceptual problems.

Although two of the children described here
would probably have done well without specific
educational therapy, each family chose tutor-
ing as a preventive measure. Our experience
shows that remedial care is easier and emo-
tional problems are lessened by early identifi-
cation of children with learning disabilities.
Physicians must be alert to the possibility of
perceptual problems in children with early
onset of seizures and refer them for testing
prior to their entry into school.

ACKNOWLEDGMENTS

The author wishes to thank Harris D. Riley,
Jr., MD, for editorial assistance in preparing
this manuscript.

REFERENCES

1. Clements SD: Minimal Cerebral Dysfunction in Children: Terminology
and Identification. Washington, US Government Printing Office, 1966.

2. Tarnapol L: Introduction to children with learning disabilities in Tar-
napol L (ed): Learning Disabilities: Introduction to Educational and Medical
Management. Springfield, Charles C Thomas, 1971, p. 17.

P.O. Box 26901, Oklahoma City, Oklahoma 73190

THE UNIVERSITY OF OKLAHOMA
COLLEGE OF MEDICINE

WEEKLY AFTERNOON OF CONTINUING EDUCATION

FIRST SEMESTER— EVERY WEDNESDAY

September 3rd — December 31st, 1975

Developed by The Department of Medicine, Office of Continuing Medical Education for Physicians

University of Oklahoma Health Sciences Center
Registration fee: $30.00 per semester

TIME

12:00 to 1 :00 p.m.

1 :30 to 2:30 pm
1 :30 to 2:30 pm
1 :30 to 2:30 pm
2:45 to 3:45 pm
4:00 to 5:00 pm
4:00 to 5:00 pm
4:00 to 5:00 pm

FIRST SEMESTER SCHEDULE

CONFERENCE

Medical Grand Rounds

Pulmonary Disease Conference
Hematology-Oncology Conference
Gastroenterology Conference
Pulmonary Problem Case Conference
Cardiology Conference
Infectious Disease Conference
Renal Conference

LOCATION

East Lecture Hall
Basic Science Building
C007 Everett Hospital
A001 Everett Hospital
C002 Everett Hospital
C007 Everett Hospital
C007 Everett Hospital
C002 Everett Hospital
A27 V.A. Hospital

This program is acceptable for Category I credit toward the Physician’s Recognition Award of the American Medical
Association and the American Academy of Family Practice on an hour for hour basis.

Journal / October 1975 / Volume 68

391

Oklahoma State Department Of Health
The Goal — Clean Air

The health hazards of breathing polluted air
are quite well documented. Prolonged exposure
to air pollution increases the morbidity and
mortality rate of respiratory diseases. The Air
Quality Service of the Oklahoma State De-
partment of Health is charged with the respon-
sibility of monitoring pollutant levels in the
ambient air, keeping emission inventories
from all major sources, reviewing performance
standards of controls, investigating complaints
and achieving overall compliance with re-
quired standards.

The Air Quality Service maintains a state-
wide air surveillance network that monitors
the concentrations of particulate matter, sul-
phur dioxide, nitrogen oxides, photo-chemical
oxidants and carbon monoxide. The primary
standards for these pollutants allow an ade-
quate margin of safety to protect the health of
the public, while the secondary standards aim
to protect the public welfare from any known
or anticipated adverse effects associated with
the presence of air pollutants.

Annually the Air Quality Service prepares

COMMUNICABLE DISEASES IN OKLAHOMA FOR AUGUST, 1975

DISEASE

August

1975

August

1974

July

1975

TOTAL TO DATE
1975 1974

Amebiasis

Brucellosis

—

Chickenpox

950

806

Encephalitis, Infectious

Gonorrhea (Use Form ODH-228)

1324

1107

1133

8578

7391

Hepatitis, A, B, Unspecified

540

703

Leptospirosis

—

Malaria

—

Meningococcal Infections

—

Meningitis, Aseptic

Mumps

183

369

Rabies in Animals

112

Rheumatic Fever

—

Rocky Mountain Spotted Fever

Rubella

—

Rubella, Congenital Syndrome

—

Rubeola

—

126

Salmonellosis

143

172

Shigellosis
Syphilis, Infectious

238

108

(Use Form ODH-228)

Tetanus

Tuberculosis, New Active

221

194

Tularemia

Typhoid Fever

Whooping Cough

News From
The Oklahoma State
Department of
Health

an Oklahoma Air Quality Report, available for
free distribution in limited quantities, which
presents a statistical analysis of pollutant data
and provides information for trend analysis
and formulation of control strategy. Generally
the conditions of Oklahoma air are steadily
improving as manifested in the reports. In
1974 the particulate concentrations met the
primary annual standard at 79 monitoring
sites compared to 73 in 1973. Reductions were
also noted in other categories.

The designation of Oklahoma City and Tulsa
and their vicinities as Air Quality Mainten-
ance Areas marks one step in long-range plan-
ning undertaken by the Service to facilitate
the attainment and maintenance of clean air
standards to the year 1985. The service is con-
tinuing in these and other areas to ensure that
the Oklahoma air is clean. □

392

Oklahoma State Medical Association

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance
Springfield, Mass.

For additional details and application form, please contact

Jim Thaxton

Administrator

720 N. W. 50th Telephone 405 848-7661

P.O. Box 18593 Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

DOCTOR, WHAT WILL YOU EARN?

It depends, of course, on your age and annual earnings, but the amount can quite reasonably
exceed $400,000.

Is this logical? Not when you can participate in the . . .

O.S.M.A. GROUP DISABILITY INCOME PROGRAM

Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION
. . . gives you individual coverage at low group rates.

. . . offers flexible waiting periods at your option.

. . . guarantees you an income when you are disabled from an accident or sickness.

. . . offers optional Indemnity from $200. 00 to $2, 500. 00 per month.

. . . pays for lifetime on accident and up to age 65 on sickness.

For Additional Information, call or write

Jim Thaxton, Bill Howard or Rodman A. Frates
C. L. FRATES & COMPANY, INC.

720 N.W. 50th P.O. Box 18695
OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848-7661

Journal / October 1975 / Volume 68

393

Governor’s Workmen’s
Compensation Commission
Begins Study

Governor David Boren has charged his Spe-
cial Advisory Committee on Workmen’s
Compensation with the responsibility of study-
ing every aspect of Oklahoma’s Workmen’s
Compensation Laws. In a letter to Senator Ed
Berrong, Chairman of the panel, Governor
Boren said ". . .Oklahoma benefits are among
the very lowest in the entire nation; while, at
the same time, the rates for insurance prem-
iums being paid by our employers remain
among the highest of all surrounding states.
Something must be radically wrong with our
present system which has allowed this imbal-
ance to continue for so many years.”

The Governor’s letter, read and distributed
to each member of the Commission, outlined
areas for study and correction. While express-
ing concern over low benefits and high prem-
iums, the Governor also challenged the effic-
iency of the present system. "No system of . . .
Workmen’s Compensation is free,” said the
Governor. "It already costs a great deal of
money just to provide the present system to-
gether with its low level of benefits. This
should not deter us in our efforts to make our
Workmen’s Compensation system a model for
the nation in providing prompt and realistic
help to those who suffer loss due to job related
injuries . . . but any such increases must be
made in a responsible manner which will in-
sure that these higher benefits go only to those
workers who are genuinely injured.”

The Governor assured the Commission that
one of his top legislative priorities will be the
reform of the Compensation Act, and asked
that the following points be considered:

(1) Extension of benefits to the thousands of
employees who are not presently covered;

(2) An increase in benefits for the injured
worker (now limited to $50.00 per week);

(3) A rehabilitation program for the injured;

(4) An administrative section to assist the
Industrial Court in expediting cases.

(5) The creation of an impartial medical pan-

394

el to review cases when a significant variance
in medical opinion exists.

The association is represented on the Com-
mission by David Bickham, Associate Execu-
tive Director, who participated in a similar
study several years ago. "The system has
changed little, if any, since the 1968 study,”
said Bickham. "The testimony presented then
is just as appropriate today. Our Occupational
Medicine Committee and Legislative Commit-
tee are reviewing previous studies and prepar-
ing comments for the Commission. Most of the
things suggested by the Governor have been
recommended before. We hope the Governor
and legislative leaders will exert the necessary
political pressure to accomplish reform, but we
know it’s an uphill battle.” □

GAO Says SRS Funds
“Face Exhaustion”

Watchdog of federal spending, The General
Accounting Office, reports that Social
Security’s trust funds "face exhaustion in the
near future because of increased benefit levels
due to inflation, and high unemployment caus-
ing reduced contributions . . .”

The GAO announcement may have delivered
a death blow to the possibility of National
Health Insurance plans relying on Social Secu-
rity financing. According to GAO, projections
covering the next 75 years show that the Social
Security system will also incur a large, long-
range deficit because of the decreasing birth-
rate and the rising cost of living.

In order to alleviate the situation, GAO
pointed out, Congress will have to approve
some of the remedies already suggested by var-
ious advisory bodies, including financing of
Medicare Part A out of general revenues, the
equivalent of adding a new $9 billion annual
spending program.

The money saved for Social Security, $9 bil-
lion, would be used to support other Social Secu-
rity programs, primarily the main retirement
disability program. Social Security taxes
would not be changed, but federal corporate
and income levies presumably would have to
furnish an extra $9 billion.

Unless such steps are taken, GAO warned,
"there may be no alternative to increasing (So-
cial Security) taxes” or the wage base or
both. n

Oklahoma State Medical Association

Oklahoma Supreme Court
Decides Optician Case

An optician may use a keratometer or
ophthalmometer to aid in the fitting of contact
lenses according to the Supreme Court Deci-
sion in the case of State of Oklahoma versus
Leonard Reeser.

The decision, in which all Justices con-
curred, also ruled that an optician may not du-
plicate lenses of any type without a written
prescription. In reaching this latter decision,
the court relied on a 1955 Oklahoma case Wil-
liamson versus Lee Optical of Oklahoma. In
that case the court construed a state statute to
say that no optician could supply a lens,
whether it was a new lens or a duplicate of a
lost or broken lens, without a written prescrip-
tion.

Because of this Lee Optical decision, the Su-
preme Court reiterated the necessity for a
"written” prescription from an ophthal-
mologist, oculist, or optometrist before an op-

(Continued from Page 374)

In setting up this Professional Liability
Study Commission, we must constantly keep in
mind that their group is a part of the Okla-
homa State Medical Association organiza-
tional structure, and in doing so the Commis-
sion will work with the related committees and
councils of the Association. Any final plans
reached by this Commission will be presented
to the Board of Trustees or to the House of Del-
egates for final approval.

The work of the Study Commission will be of
a priority nature. They will receive my per-
sonal support so long as they keep in mind that
their duty is for the good of all of the member-
ship of the Oklahoma State Medical Associa-
tion. I know they will work hard on this impor-
tant project and I also know they will make
progress. I know too, that this Study Commis-
sion at times will be disappointed and frus-
trated and that the goals of their game plan
cannot be accomplished in one year. As in the
past, a healthy legal atmosphere will require
continuing vigilance and day to day manage-
ment decisions.

The Study Commission has already had its
first meeting, and I personally was very en-
thused with the many and varied activities
that were discussed. I have been directed, as

Journal / October 1975 / Volume 68

tician could duplicate a regular or contact lens.

In regard to opticians fitting contact lenses,
the Supreme Court said, "the optician does not
decide whether or not a patient may wear con-
tact lenses. This is indicated on the prescrip-
tion. The optician does not use the keratome-
ter to measure refraction or astigmatism. The
patient is advised to return to the examiner for
assurance as to proper fit. If all ophthal-
mologists would be required to purchase a
keratometer and take the extra time to use it
in making measurements for the fitting of con-
tacts, this might result in a disservice to the
patient in added expense.”

The Oklahoma State Medical Association
filed a brief in the case while it was pending
before the Supreme Court. Ophthalmologists
in the state of Oklahoma were concerned be-
cause no ophthalmologist had testified at the
original trial and subsequently the trial court
did not have expert testimony on the views of
ophthalmologists toward opticians and the use
of the keratometer. □

President of your Association, to discuss with
the authorities of the University of Oklahoma
Health Sciences Center the possibility of teach-
ing more about malpractice to Junior and
Senior Medical Students. It is our under-

standing that a professional liability course is
being taught only to the freshman class in the
College of Medicine. The Commission feels
that more could be gained by offering the
course to students who are nearer to gradua-
tion. The Study Commission is probing the
idea of offering more professional liability
study courses, with a possibility of decreasing
one’s insurance rate when satisfactorily com-
pleting one of the prescribed seminars. I would
expect that such a course would need to be re-
peated approximately every three years in
order to remain on the reduced rating list.

It is my personal opinion that this pro-
fessional liability study program will be a
great asset to our association in the years
ahead in maintaining the number one position
in our statewide insurance program. I can’t
help but be very enthusiastic about this impor-
tant subject area.

I request, once again, that every member of
our association unite to keep our insurance
program stable.

, fa &

395

BEVERLY HILLS HOSPITAL
BEVERLY HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

PSYCHIATRY

Jackson H. Speegle, MD
John T. Holbrook, MD

Fred H. Jordan, MD
Joseph H. Lindsay, MD

PSYCHOLOGY

George R. Mount, PhD Tom I. Payton, MS

Donald L. Whaley, PhD Patrick R. Barnes, MS

EDUCATION DIRECTOR

William E. Nix, PhD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND R.T. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

396

Oklahoma State Medical Association

Internal Medicine Course
Available Via Television

Physicians wishing to brush up on their in-
ternal medicine skills will be able to do so this
fall for the first time without having to travel
to distant college or university facilities.

By use of the televised instruction system
sponsored by the Oklahoma State Regents for
Higher Education, state physicians may enroll,
via talk-back television, in the internal
medicine review course being offered Sep-
tember 18th-December 18th by the University
of Oklahoma Health Sciences Center.

Dale Groom, MD, Review Course Coor-
dinator, said the course is being scheduled on
talk-back television to eight physicians living
outside the Oklahoma City area in updating
their medical skills.

The internal medicine review course is of-
fered annually by the Health Sciences Center
Office of Continuing Medical Education for
physicians and the Department of Medicine. It
covers such topics as clinical pharmacology,
solid tumors, hemotologic oncology, immunol-
ogy, neurology, hyperlipoproteinemia, gene-
tics, bleeding disorders, rheumatology, and
allergy-immunology.

Physicians interested in taking the course
should contact the local facility housing the
closed circuit television equipment and class-
room space. The course operates each Thurs-
day night from 5:00 until 6:30 pm and will be
charged the course fee of $35 and an additional
$15 transmission fee.

Cities able to receive the talk-back television
class and locations of the facilities are: Okla-
homa State University, Stillwater; University
of Tulsa; Oral Roberts University, Tulsa; Tulsa
Junior College; Tulsa Vo-Tech; Phillips Uni-
versity, Enid; Northeastern Oklahoma State
University, Tahelquah; Bartlesville Wesleyan
College; Phillips Petroleum Company,
Bartlesville; Bureau of Mines, Bartlesville;
Continental Oil and Ponca City Hospital,
Ponca City; Muskogee Veterans Admin-
istration Hospital; Muskogee High School; and
Northern Oklahoma College, Tonkawa.

Doctor Groom said the internal medicine re-
view course, whether taken at the Health Sci-
ences Center or via talk-back television is ac-
ceptable for one and one-half hours per session
in Category I for the Physicians’s Recognition
Award of the AMA and the American Academy
of Family Physicians. □

HEALTH CARE MANAGEMENT

MASSES OF PAPERWORK AND SLOW RECEIVABLES
. . . these two enemies are overwhelming todays Medical
Office! How to deal with these two is the ‘‘number one
business problem’’ for many doctors.

HCM’s system is simple, easy to learn, requires no
special equipment, is flexible, and can follow along the
lines of your present business office procedures.

For further information, contact:
Gene Highfill

Academy Computing Corporation
3535 NW 58th — Suite 102
Oklahoma City, Oklahoma 73112
405/947-7746

Journal / October 1975 / Volume 68

397

news

HSA Task Force Recommendations
Nearing Completion

The state’s Health System Agency may soon
be officially organized. A Governor’s Task
Force will soon complete its function of prepar-
ing suggestions on the corporate structure and
composition of the first HSA Board of Directors
for David Boren. Apparently, the study group
has decided that a private "not-for-profit”
corporation should be organized to implement
requirements of Public Law 93-641 — The Na-
tional Health Planning and Resources De-
velopment Act of 1974. The non-profit corpora-
tion is one of the three options available to the
Governor under the law. The others were
"units of government” or a "regional planning
body.” Most observers expected the new
corporation approach which obviates the cer-
tain political competition and inter-agency
fighting if either of the other methods were
selected.

Of less certainty is the manner in which the
original board will be selected. Boren’s deci-
sion to elect the single HSA option has created

substantial problems in selecting the first-
governing body. Under the law (Oklahoma and
Federal) it appears that the board will have
thirty members. Sixteen, according to the Fed-
eral Act must represent consumers. The other
14 are to be selected from the ranks of direct
and indirect providers — the definition of
which includes everyone from physicians to
health insurance salesmen. The major provider
organizations are vying for specific representa-
tion on the board, and rural representatives
want to be assured of an adequate voice.
Others feel the sub-area councils (six) should
be organized and submit nominees for rep-
resentation on the original board.

Members of the Task Force are working with
various options for the Governor’s consid-
eration. Each of the proposals will attempt to
provide for nominees from sub-area councils
and government; and consideration of rep-
resentation by sub-area population.

Regardless of their suggestions on forma-
tions, Governor Boren will choose the first
board and sub-area councils, his appointees
may well determine the future course of health
planning in Oklahoma. □

SPONSORED BYTHE OSMA

Washington National Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE
I DISABILITY INCOME INSURANCE

Contact Association Counselors:

Jim Thaxton, Bill Howard or Rodman A. Prates

Administrators

720 NW 50th

PO Box 1 8593 405 842-3735 Oklahoma City 73118

398

Oklahoma State Medical Association

Generic Drug Marketing
Stymied by Federal Court

A Federal court ruling threatens to cramp
the Food and Drug Administration’s plans to
make it easier for "generic drug” makers to
market their products quickly after patent pro-
tection runs out on brand-names.

An order by US District Judge, June Green
in Washington, DC, blocked FDA from allow-
ing Zenith Laboratories of North Vale, New
Jersey, to market a generic version of chlor-
diazepoxide without first obtaining a new drug
application. The ruling was sought by Hoff-
man-LaRoche, Inc., which markets the product
as Librium.

Judge Green said the NDA requirement for
generic drugs has an anticompetitive affect.
But "the overriding interest in insuring the
health and safety of the public through compli-
ance . . . requires the result reached here.”

Securing a new drug application for a prod-
uct is a lengthy and extensive procedure, re-
quiring test data, etc., and would delay for a
long period introduction of competitive "gener-
ic” drugs in cases where patents have lapsed.

If upheld by higher courts, the ruling could
hurt the HEW Department’s controversial
maximum allowable cost . . . known as MAC
. . . program intended to foster purchase of
generic drugs by Medicaid patients. MAC has
been challenged in federal court by the Ameri-
can Medical Association. □

Oral Diabetic Drug Warning Debated

Strong arguments for and against warning
labels for oral diabetic drugs were heard at an
unusual one-day hearing conducted by the
Food and Drug Administration. The argument
has become one of the agencies keenest
medical- scientific controveries in the past five
years.

A new British study and a testimony of one
of the original American investigators casts
some doubt on the validity of the scientific data
FDA had been relying upon in its efforts to
crack down on oral hypoglycemics. On the
other hand, one of Ralph Nader’s health teams
contended the warning label was insufficient
and called for written consent by patients be-
fore taking the oral products.

The hearing was called to further air the dif-
ferences of opinion on the FDA’s proposed
warning that there may be increased risk of
cardiovascular death in diabetic patients

treated with the oral drug. The proposal is
based on a 1961-1970 clinical study by the uni-
versity group diabetes program which claimed
the heart disease death rate was twice as high
among patients treated with the oral drugs
compared with those on insulin or special diets.

A double blind study by University of Lon-
don professor Harry Keen suggested evidence
of long-term benefits from Tolbutamide and
Phenformin and no long-term cardiovascular
toxicity. An FDA official said this latest study,
carried out over an eight-year period, will re-
quire close consideration.

The FDA received information that the
UGDP study may have been prejudiced by a
conflict of interest on the part of one of the
investigators. It was told that it "might be on
mighty thin ice” if it goes forward with its
plans to require warning labels without first
investigating whether the study was actually
valid. □

Editorial

(Continued from Page 373)
consistent with the findings reported else-
where in that dramatic elevations of cholester-
ol (up to 500 mg/dl.) and CPK (up to 1435
units) are virtually always seen in profound
hypothyroidism, yet all return to normal as
euthyroidism is approached.

Hypothyroidism need no longer be a guess-
ing exercise in medicine. The tools to recognize
it are available and should be used. James L.
Males, MD, Department of Medicine, Oklahoma
City Clinic and Section of Endocrinology, De-
partment of Medicine, University of Oklahoma
Health Sciences Center. □

REFERENCES

1. Brown, J. and Chopra L, Cornell, J., et al: Thyroid Physiology in Health
and Disease. Ann. Int. Med. 81:68-81, 1974.

2. Solomon, D., Benotti, J., et al: A Nomenclature for Tests of Thyroid Hor-
mones in Serum: Report of an Committee of the American Thyroid Associa-
tion. J. Clin. Endocrin. 34:884-890, 1972.

3. Chertow, B., Motto, G. and Shah, J.: A Biochemical Profile of Abnormali-
ties in Hypothyroidism. Am. J. Clin. Path. 61:785-88, 1974.

4. Cao, A., De Virgiliis, S., Trabalza, N„ et al: Serum Creatine Phosphokin-
ase Isoenzymes in Congenital Hypothyroidism. J. Pediatr. 78:134-5, 1971.

Remember these dates —

May 6th, 7th, 8th, 9th, 1976
OKLAHOMA MEDICAL SUMMIT ’76

Lincoln Plaza Forum
Oklahoma City, Oklahoma

Journal / October 1975 / Volume 68

399

DEATHS

EARL D. McBRIDE, md
1892-1975

Earl D. McBride, MD, 84-year-old,
retired founder of the Bone and Joint
Hospital and McBride Clinic in Okla-
homa City, died September 20th, 1975.
As an orthopedic surgeon, Doctor Mc-
Bride pioneered work for crippled chil-
dren in Oklahoma. A 1914 graduate of
Columbia University College of Physi-
cians and Surgeons, New York, Doctor
McBride served with the Medical Corps
in World War I and as a consultant to
the Surgeon General of the US War
Department after World War II. In
addition to his private practice, he was
a Clinical Professor of Orthopedic Sur-
gery at the University of Oklahoma
Health Sciences Center.

Doctor McBride was active in many
medical organizations having served as
the first President of the Oklahoma
City Clinical Society; was a charter
member of the Association of Bone and
Joint Surgeons; and a member of the
American Orthopaedic Association, the
Clinical Orthopaedic Society, the
Southern Medical Association, the In-
dustrial Medical Association and the
American Fracture Association. He
was a Life Member of the Oklahoma
State Medical Association.

CHARLES W. JOYCE, MD
1881-1975

Charles W- Joyce, MD, a Fletcher
physician for 70 years, died in Lawton,
August 31st, 1975. Born in Westfield,
North Carolina, September 22nd, 1881,
Doctor Joyce was graduated from the
University of Tennessee College of
Medicine in 1903. He practiced in
Elgin and Wheatland before moving to
Fletcher in 1912.

Doctor Joyce was honored in 1954
when the OSMA made him a member
of the Fifty-Year Club and again in
1957 when he received an OSMA Life
Membership.

ROBERT H. AKIN, MD

1904- 1975

Robert H. Akin, MD, an Oklahoma
City urologist, died September 16th,
1975. A native of Watonga, Oklahoma,
Doctor Akin was graduated from the
University of Oklahoma College of
Medicine in 1928. Doctor Akin was ac-
tive in urological circles and held
memberships in the South Central Sec-
tion of the American Urological
Association, the Sociedad Mexicana de
Urologia, the American Urological
Association, the American College of
Surgeons and was a Diplomat of the
American Board of Urology. In 1971,
the Oklahoma State Medical Associa-
tion presented Doctor Akin with a Life
Membership.

RAYMOND E. SEEDERS, MD
1892-1975

Word was received by the Oklahoma
State Medical Association, that a 1927
University of Oklahoma College of
Medicine graduate, Raymond E. Sel-
ders, MD, had died August 31st, 1975,
in Houston. Doctor Selders was a re-
tired general surgeon and will be re-
membered by many Oklahoma
physicians.

GLENN H. YEARY, MD

1905- 1975

Newkirk physician, Glenn H. Yeary,
MD, 70, died September 12th, 1975. A
native of Elmore City, Oklahoma, Doc-
tor Yeary was the brother of E. Curtis
Yeary, MD, a Ponca City physician. He
graduated from the University of
Oklahoma School of Medicine and took
his internship at Kansas City General
Hospital before establishing his prac-
tice in Newkirk in 1933.

Doctor Yeary had earned the ad-
miration and love of the small com-
munity for his long years of devoted
service to its citizens. He was also
recognized as one of the most astute
medical diagnosticians in Kay
County. til

400

Oklahoma State Medical Association

Offering complete private Psy-
chiatric Services using the
Therapeutic Community ap-
proach in an open setting.

Fully Accrediated
60 Beds

MEDiCENTER PSYCHIATRIC
HOSPITAL

1505 Eighth Wichita Falls, Texas 76301

Services Available

• Psychotherapy Individual and Group

• Chemotherapy

• Recreational Therapy

• Occupational Therapy

• Psychological Testing

• Psychiatric Social Worker Services

• Neurological Consultation

• Electro-Convulsive Therapy

• Clinical Laboratory

• X-ray

• Pharmacy

• Physical Therapy

• Medical Consultations

Miscellaneous Advertisements

CLAREMORE, OKLAHOMA is in need of
one or two young, board certified general sur-
geons to form the foundation with three intern-
ists of a new medical group. A 105-bed fully
accredited, well-equipped hospital is in opera-
tion. Include complete vitae in first corre-
spondence. Interested individuals should con-
tact Key D, The Journal, Oklahoma State Med-
ical Association, 601 N.W. Expressway, Okla-
homa City, Oklahoma 73118.

FOR SALE: Complete x-ray and dark room
equipment with accessories, view boxes, com-
plete examination room equipment, office
equipment, diathermy and ultra sonic, ultra
violet and infrared lamps, electrocardiograph,
miscellaneous surgical and orthopedic instru-
ments. Please contact A. B. Smith, MD, 408
South Main Street, Stillwater, Oklahoma
74074. Phone 405 372-565 6 (office) or 405
372-6460 (home).

INTERNIST: Immediate opening for chief
medical service of 408-bed Veterans Admin-
istration Center located in warm climate of
Texas. Sixty-five miles from downtown Dallas.
Salaries based on education, experience and
background. Paid vacation, sick leave, mal-
practice and life insurance, and other fringe
benefits. Interested physicians please write or
call George H. Hassard, MD, Chief of Staff,
Sam Rayburn Memorial Veterans Center,
Bonham, Texas 75418. Telephone 214
583-2111, ext. 212. Inquiries confidential. An
equal opportunity employer.

Journal / October 1975 / Volume 68

401

news

PRIMARY CARE PHYSICIAN. Kansas
State University Student Health Center and
University Hospital anticipates an opening in
its professional medical staff beginning Oc-
tober 1st, 1975. The Center and Hospital is ac-
credited by the Joint Commission on Accred-
itation of Hospitals and includes a busy out-
patient clinic, laboratory, diagnostic X-ray,
mental health, pharmacy, physical medicine
and 26-bed hospital. We are looking for an
energetic primary care physician to join our
medical staff of eight, with a supporting pro-
fessional staff of seventy. Activity involves
general practice with some office orthopedics,
office gynecology, and office ophthalmology.
Office hours are 8-5 with on call schedule av-
eraging four to five days per month. Salary
range: $25,500-$30,000 depending on experi-
ence and qualification. Fringe benefits include
one month vacation plus paid postgraduate
education meetings. Experience in private
medical practice is desired. Kansas State Uni-
versity is an equal opportunity employer. For
further information please write Director,
Lafene Student Health Center and University
Hospital, Kansas State University, Man-
hattan, Kansas 66506.

402

EXCELLENT OPPORTUNITY for general
practice in nice community near Lake Eufaula.
Privileges in modern 44-bed hospital, with
plans being made for a new 60-bed community
hospital. Space available for three GP’s in clinic
adjoining hospital that already has an abun-
dant patient load. Can expect full-time practice
in a short time, along with time off coverage.
Guaranteed starting salary — $40,000.00 —
very rapid chance of advancement — with
capabilities of earning much more. Located in
an ideal community from which the patients
are drawn from an area of approximately
20,000 population. Ideally located on Highway
1-40 and 75 — an hour’s drive to Tulsa theaters
and restaurants, and only an hour and a half
from downtown Oklahoma City. Only a few
minutes drive to Lake Eufaula, Fountain Head
Lodge being only 25 miles away. There is a
new high school and a new grade school. A
small town having all the advantages of a city.
A wonderful place for raising children. This is
a marvelous opportunity for a family type
practice with time off. Call Carlton E. Smith,
MD, at 918 652-3337, Henryetta, Oklahoma —
collect.

Oklahoma State Medical Association

Immunization Action Month

The month of October has again been desig-
nated as Immunization Action Month and
auxiliary members are urged to join in the
cooperative effort to reach and motivate par-
ents of pre-school children to immunize against
polio, measles, rubella, mumps, diphtheria,
pertussis and tetanus. Surely we will do every-
thing we can, either individually or as an aux-
iliary, to reach the unprotected children in our
communities. One of the objectives of the aux-
iliary is to assist the medical association in its
program to improve the quality of life through
health education and service. We can play a
vital role in our own community by telling the
public preventive medicine does work.

Immunization Action Month was initiated in
1973. It was designed to break the apathy to-
ward vaccine preventable disease throughout
the United States. According to information
from the Immunization Division of the Center
for Disease Control in Atlanta, Georgia, the
efforts have been successful. The 1974 US
Immunization Survey shows that an increase
has occurred for all vaccines in the one to four
year age group. The extra effort put forth by
participating organizations during Immuniza-
tion Action Month in 1973 and 1974 have re-
versed the declining trend. This year, however,
we must not grow complacent but increase our
efforts, keeping in mind the immunity levels
among one to four-year-old children are still
low enough to sustain substantial spread of
disease, including outbreaks.

David E. Adcock, administrator of the
Immunization Program in Oklahoma, has ex-
pressed appreciation for our help and support
and has asked that we continue to provide
Oklahoma parents with information explain-
ing the need for adequate and complete
immunization early in life. We must continue
to provide information not only on a one-month
basis as we do in Immunization Action Month

Journal / October 1975 / Volume 68

but on a 12-month basis. Your county auxiliary
can help by:

1. Checking your own family immunization
record now.

2. Be informed and inform others. Know the
threat of childhood diseases and be informed
about the means and methods of combating
them.

3. Work with other participating organiza-
tions. Ask your medical association and your
health department how you can work with
them.

4. Reach parents through clubs, church
groups, county fairs, PTA, etc.

5. Sponsor spot announcements on radio and
TV.

6. Ask the mayors of the towns and cities in
your county to join Governor Boren in issuing
an IAM Proclamation calling on all our citi-
zens to join in a crusade to assure complete
immunization for all our children.

An interesting Immunization Project came
to us from our "Idea Exchange” with other
states. One state auxiliary launched its
immunization action at the request of and in
cooperation with their state medical associa-
tion. Everything from flyers in grocery shop-
ping bags to messages on milk cartons charac-
terized the all-out effort in delivering the mes-
sage, "You Can Prevent It.” In order to reach
the parents of new-born infants the auxiliary
printed a brochure to be taken home from the
hospital. It not only contained helpful informa-
tion but a handy record card for immunization
records.

Since each county is different and so are the
talents and personalities of its county auxil-
iary members, only you can decide how you can
work best with the other participating
organizations in the Immunization Program.
Jewell Coates - Community Health Chairman -
Auxiliary to the Oklahoma State Medical
Association. □

XXXV

Professional Liability Commission Holds
First Meeting. A blue ribbon commission au-
thorized by the Board of Trustees and ap-
pointed by Arnold G. Nelson, MB, President,
has held its first meeting to discuss the mal-
practice insurance crisis. The panel, composed
of medical specialty representatives, OSMA of-
ficers, insurance representatives, defense at-
torneys and the general council spent Sunday
afternoon in a lengthy meeting discussing the
problems of availability and cost of liability in-
surance. C. Alton Brown, MB, head of OSMA’s
Council on Insurance, chairs the Commission
who will make recommendations to OSMA’s
Board of Trustees for corrective action. It is
anticipated that a number of legislative rec-
ommendations will result from the Commis-
sion hearing.

Other areas of concern include legal education
for physicians — how to avoid being sued and
continuing medical education to insure up-to-
date information on the latest medical tech-
niques and knowledge.

While Oklahoma enjoys a favored status
among all states nationwide as far as insur-
ance rates are concerned, the commission
fears that it is simply a matter of time before
the "crisis” reaches the state.

Preventative measures of a relatively minor
nature could avert the East and West coast
disasters that drew national attention to the
problem, said C. Alton Brown, MB, Chairman
of the Commission.

HEW Team To Visit Oklahoma. A team of
health officials representing Theodore Cooper,
MB, Secretary of Health, Bepartment of
Health, Education and Welfare, will visit
Oklahoma to finalize the Hospital Cost Effec-
tiveness Plan (utilization review). "Because
the plan is now being considered as a national
prototype, its evaluation has become extremely
significant,” said Bon Blair, Executive Birec-
tor of OSMA. "In fact, if the plan is successful it
could substantially alter the implementation

xxxvi

of PSRO.” Labeled "Focused Review” by fed-
eral officials, the plan waives most review re-
quirements for institutions that deliver care
within acceptable norms. "Our idea” explained
Blair, "was to design a system that was least
disruptive to physicians and hospital routine.
CEP is a retrospective analysis of hospital data
that identifies problems. We assume that
physicians and institutions will want to correct
deficiencies when they have been isolated.

The Oklahoma Foundation for Peer Review
will monitor the program when it has received
formal approval. Bavid Matthews, Secretary,
Bepartment Health, Education and Welfare in
a meeting with Senator Bellmon and OSMA
officials, indicated he would approve the plan if
recommended by Boctor Cooper. Cooper, one of
the earliest supporters of the alternative ap-
proach, has approved the plan subject to suc-
cessful resolution of minor legal problems.

Medicare Leaflet Spreads to Other States.
Louisiana and Arkansas followed Oklahoma’s
lead in giving widespread distribution to the
"Your Medicare Benefits are Being Cut” leaf-
let. Oklahoma physicians have already used
250,000 of the leaflets and reports from the
other states indicate that their initial supplies
were quickly depleted.

OSMA Annual Business Meeting to be
Separated from Summit. The Board of
Trustees has approved recommendations by
Arnold G. Nelson, MB, that the annual House
of Belegates meeting be held at a time differ-
ent than that of Summit ’76. "Annually we re-
ceive a considerable number of complaints
from physicians who cannot attend the Sum-
mit Scientific Sessions because they are in-
volved in the business aspects of association
affairs,” said Nelson. "By moving the meeting
to another time we eliminate conflicts and can
reduce business sessions to the minimum
time.” Tentative plans call for the House of
Belegates meeting to be held at the Skirvin
Hotel, April 10th and 11th, 1976. □

Oklahoma State Medical Association

November

1975

Vol. 68, No. 11

of the Oklahoma State hiedical Association

EDITORIAL BOARD

MARK R. JOHNSON, MD
Editor-in-Chief

HARRIS D. RILEY, Jr., MD
Editor

ROBERT G. TOMPKINS, MD
Editor

ERNEST LACHMAN, MD
Corresponding Editor
Regents Professor Emeritus
of Anatomical and
Radiological Sciences,
University of Oklahoma
Health Sciences Center.

OFFICERS

ARNOLD G. NELSON, MD
President

WILLIAM M. LEEBRON, MD
Vice-President

HAVEN W. MANKIN, MD
Secretary-Treasurer

STAFF

DON BLAIR
Business Manager

LOUISE MARTIN
Editorial Assistant

SUBSCRIPTION TO THE JOURNAL is in-
cluded in membership fees. Other subscrip-
tions are $6.50 per year or $1.00 per copy
with each request subject to approval of the
Editorial Board.

POSTMASTERS: Send all change of address
notices to 601 N.W. Expressway, Oklahoma
City, Okla. 73118.

CONTENTS

editorial

Drug Substitution : Many Promises — Few Results 403
President’s Page ....... 404

scientific

The Electric Tic Procedure : A Safe Percutaneous

Method for Relief of Trigeminal Neuralgia,

Richard V. Smith, MD ..... 405

Guidelines to Biopsy of the Breast, Frank McGregor,

MD, Arthur F. Hoge, MD and Joe M. Parker, MD 408

Congenital Anomalies In Infants And Children, 1875,

Ronald D. Greenwood, MD . . . . 412

Intrauterine Infection, 1808, Ronald D. Greenwood,

MD 416

special

The Cost of Hospitalization - Oklahoma Hospitals,

James E. Perry ....... 423

News from the Oklahoma State Department of

Health ......... 427

news

Trustees Continue Search For Alternative UR Plan 430
Malpractice Insurance Problems Studied . . 432

Program Completed for AMA Tulsa Regional Meet-
ing ......... 434

Proposed Legislation Would Overhaul Workmen’s

Compensation System ...... 436

Medical Assistants Schedule Third Session . . 436

Drug Substitution Bill Due Reconsideration By Okla-
homa Legislature ....... 437

Rural Health Week Slated For Bicentennial Year . 438

OSMA Fills Communications Post .... 438

Oklahomans Set For AMA Meeting .... 438

Statement of Ownership ...... 439

Deaths ......... 439

OSMA To Sponsor Pension Program For Physicians 440

Miscellaneous Advertisements ..... 446

Woman’s Auxiliary ....... 447

Index to Advertisers ...... xxi

The Last Word xxiv

( Cover Art By William Cason )

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Additional information available to the profession on request.
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Indianapolis, Indiana 46206

Oklahoma State Medical Association

Drug Substitution: Many
Promises — Few Results

Not long ago, a physician in Eau Claire,
Wisconsin, closed his practice and moved to
another state. His reason . . self-seeking po-
litical interferences have become so intolerable
that I can make no other possible decision.”

One of the interferences is proposed legisla-
tion that would allow drug substitution with-
out the knowledge or approval of the physician.
The same legislation that helped force the Wis-
consin physician to close his practice and leave
the state is now an issue in Oklahoma, and its
chief backer, Representative Mark Hammons,
plans to once again push for its passage. The
Hammons bill, H.B. 1160, is with the Senate
Committee on Public and Mental Health and
will be considered next year.

Substitution is superficially enticing be-
cause it allows the patient to request the
pharmacist to replace the prescribed drug with
a lower priced, generic equivalent. In fact, the
patient would be encouraged to do so because
pharmacies would be allowed to advertise a
"cost counseling” service. Drug selection, then,
would be based entirely on price. Even when
cautioned by the pharmacist, the patient would
be in total charge of drug selection. The net
effect would be to lower health care standards
in the name of non-existent savings to the pa-
tient.

The only reason for H.B. 1160 is to save
money, but based on a 1973 study, the average
consumer would have only saved 43 cents on
all of his drug purchases that year if generics
were used whenever possible. In Canada,
where substitution has been allowed for ten
years, there have been no demonstrable sav-
ings to the patient.

And what price would the patient pay for
these negligible savings? Perhaps a high one!
Not only could poorly made drugs create health
hazards, but they also could cause illnesses to
linger. If the Food and Drug Administration
could guarantee the quality of the billions of
doses of prescription drugs, there would be no
problem with choosing drugs generically.
However, the FDA cannot make such a
guarantee, and so the risks of generic substitu-
tion are high.

For example, in 1972, the US Air Force pur-
chased a foreign-made tetracycline antibiotic,
assuming that it met published standards and
was equivalent to the major brand name pro-

duct. The drug did not dissolve properly in ser-
vicemen being treated for penicillin-resistant
gonorrhea, and infections of the urinary tract
resulted. Proponents of H.B. 1160 believe that
all generic equivalents are made with the same
care, but, in this case, and in many others,
physicians have found just the opposite to be
true.

While substitution is mainly a health ques-
tion for patients, it also raises serious liability
questions for physicians who need no added
surprises. The transfer of drug selection re-
sponsibilities from the physician to the phar-
macist could involve doctors in an increased
number of malpractice claims, because the doc-
tor is almost sure to be named in any lawsuit
involving a drug-related injury or an unneces-
sarily prolonged illness. Even if the doctor is
always found not liable, the cost of defense will
force insurance rates higher and add problems
to an already crisis situation.

On the other hand, since an overwhelming
number of American citizens want drug sub-
stitution, it is an issue that must be carefully
considered, right? Wrong! According to a na-
tional survey, less than 30 per cent of the per-
sons surveyed favor the substitution of
chemically-similar drugs. In a California sur-
vey of persons aged 55 and over, 83 per cent
were opposed to delegating drug product se-
lection to the pharmacist, and this is the very
age group drug substitution is supposedly de-
signed to help.

So, substitution comes down to an issue that
potentially threatens the patient’s welfare, of-
fers no substantial savings, threatens to
heighten the malpractice insurance crisis, and
is opposed by a broad cross-section of the pub-
lic. And, yet, the Oklahoma Legislature will
probably reconsider the bill during its next
session.

There is no reason for Oklahoma to experi-
ment with a law which has already failed in
several other states and in Canada. Every
physician, pharmacist, and patient should be
familiar with H.B. 1160 and its possible seri-
ous effect on health care in this state. Richard
Hess, Director of Communications, Oklahoma
State Medical Association. D

Journal / November 1975 / Volume 68

403

president's page

For several years, the Okla-
homa State Medical As-
sociation has been concerned
about Oklahoma’s system
of workmen’s compensation.

On October 14th, David
Bickham, OSMA Associate
Executive Director, R. Bar-
ton Carl, MD, John Blaschke,

MD, and I were asked to testi-
fy before the Governor’s
Commission on Workmen’s Compensation. We
made it quite clear that we were very concerned
about the Commission’s activities.

We in Oklahoma realize the importance of a
workmen’s compensation program that is equitable
to the injured worker, the employer and the insur-
ance carrier. We stand behind the principle and
philosophy that the injured working man should
have the very best medical care, adequate benefits
while unable to work, unending efforts from all par-
ties to speed his return to the job, rehabilitation if
necessary, and adequate compensation for perma-
nent effects resulting from the disease or injury.
While we are concerned about costs, we believe costs
should be secondary to the patient’s welfare.

It has been shown that workmen’s compensation
costs in this state exceed the costs in surrounding
states. It has also been stated that the benefits here
are not in line with the cost of the program.

While we believe in quick, adequate benefits for
the injured, there is no question that a return to
employment is more desirable to the injured em-
ployee. The opportunity to earn a living while being
treated for an injury would reduce the economic dis-
aster experienced by many of our injured workers.
At the same time, it might also reduce the amount of
disability payments by allowing the worker to earn
income while receiving treatment. Under our pres-
ent system, however, it is difficult, if not impossible,
for the injured man to return to work until he has
been completely released by his attending physi-
cian.

I feel a study should be made of this aspect of
workmen’s compensation. Through education, sta-
tute, or otherwise, an environment should be
created where an injured worker can be accepted on

the job prior to final release by his attending physi-
cian. At the same time, the physician should
be relieved of his present responsibility for evaluat-
ing permanent disability. Doctors are students of
science, skilled in making scientific judgments. We
should be allowed and asked to give opinions only
on impairment of functions, not on permanent
disability.

I urge consideration be given to utilizing the work
and studies of national committees on disability
evaluation, particularly guides which are available
through the American Medical Association. These
guidebooks could aid the physician in determining
physical impairments. I would also support the crea-
tion of a panel of physicians to review medical ques-
tions which seem to have a significant divergence of
medical opinion. This panel should be composed of
physicians from all types of practice, and participat-
ing physicians should be able to obtain x-rays and
other laboratory studies previously performed by
other physicians. He should also be allowed to make
any additional tests necessary to make a proper
evaluation of the injury . The panelist-physician
should, of course, be paid for his services by the
Oklahoma Industrial Commission. Although a great
deal of study would have to be given to the medical
panel system, once operational, it would probably
save a large sum of money.

Your representatives who appeared before the
Commission looked closely at workmen’s compensa-
tion and made these specific recommendations:

1. Physicians should only determine physical im-
pairment. The question of permanent disability
should be determined by the court.

2. A medical panel should be created to resolve
medical disputes before the court.

3. A study should be made of the feasibility of a
permanent medical director for the Oklahoma In-
dustrial Court.

4. Additional safety programs should be insti-
tuted.

Those of us who testified before the Governor’s
Commission on Workmen’s Compensation felt good
progress was made. It will, of course, be necessary to
pursue our recommendations and consider others.

Once again, I ask for unity among all physicians
in this state in solving this very difficult problem.

, fa A

404

Oklahoma State Medical Association

The Electric Tic Procedure:

A Safe Percutaneous Method for
Relief of Trigeminal Neuralgia

RICHARD V. SMITH, MD

Utilizing a 1914 approach developed in
Europe with subsequent modern day
refinements , a low morbidity , highly
successful technique has been developed to
treat trigeminal neuralgia.

Trigeminal neuralgia is for the most part a
disease process affecting the elderly patient
who often harbors a brittle cardiovascular or
pulmonary status making the risks of general
anesthesia and major intracranial surgical
procedures excessively high. However, regard-

Iless of risk, the result of tic pain is very often so
incapacitating and refractory to medical man-
agement that surgery becomes the only ac-
ceptable form of treatment.

Utilizing a percutaneous technique de-
scribed by Hartel2 in 1914 to reach the foramen
ovale and gasserian ganglion, Kirschner5 in
the 1930’s placed a needle electrode into the
region of the gasserian ganglion and used

Journal / November 1975 / Volume 68

diathermy heat to coagulate the ganglion and
relieve the pain of trigeminal neuralgia.

Over the next twenty years the percutaneous
diathermy method of treating tic pain became
widespread in Europe. However, in 1951
Tonis3 reviewed and reported the complication
rate of diathermy gasserian ganglion coagula-
tion and found considerable morbidity despite
tic pain relief. Chemical methods were tried by
the same Hartel percutaneous route using
alcohol1, phenol in glycerin4, and boiling
water.3 Despite pain relief from the chemical
injections, the morbidity remained high. The
main complications of both the diathermy and
chemical methods included carotid artery in-
jury, cranial nerve deficits and brain stem in-
juries all resulting from uncontrolled spread of
diathermy current or chemicals.

From 1963 through 1970 Schurman6 in
Germany used low milliamperage intermittent
diathermy electrocoagulation of the gasserian
ganglion and retrogasserian rootlets and
achieved relief of tic pain in 93% of his patients
with minimal complications and no mortality.
Simultaneously, in the United States, Sweet
and Wepsic7 utilized a radio frequency lesion
generator to create a controlled retrogasserian
lesion with similar results.

The procedure reported in this paper is es-
sentially that initiated by Hartel’s 1914 per-

405

Tic Procedure / SMITH

cutaneous approach and subsequent modifica-
tions of lesion generating devices since the
1930’s. Sweet and Wepsic have developed the
radio frequency technique used today for the
relief of tic pain.

METHODS

The patient is given preoperative Innovar
sedation and placed on a padded x-ray table in
a comfortable supine position. Under Brevital
anesthesia, a thin wall 18 gauge spinal needle
is passed percutaneously from the cheek area
into the foramen ovale and positioned adjacent
to the clivus under fluoroscopic control. An
electrode is passed through the needle and po-
sitioned relative to the clivus depending on the
specific trigeminal division to be treated. A
precisely controlled stimulus is produced with
the patient awake. If the electrode is in the
proper position, the appropriate division pares-
thesia is elicited. Additional Brevital is admin-
istered and the radio frequency lesion is
created. Selective divisional hypalgesia is
achieved with loss of pain sensation, but a de-
gree of touch sensation is preserved. The entire
procedure requires from 30 to 90 minutes to
complete. The patient is usually ambulatory
and able to eat postoperatively and often re-
turns home the following day.

RESULTS

This paper reports eight patients who have
undergone eleven electric tic procedures be-
tween July, 1974 and April, 1975 with no com-
plications. Seven procedures were performed
for tic pain while one was performed for
intractable mandibular pain for recurrent car-
cinoma of the tonsil. The follow-up period has
been short, but all eight individuals have re-

Richard V. Smith, MD, graduated from the
University of Oklahoma School of Medicine in
1966 where he is presently Clinical Assistant in
the Division of Neurosurgery . His private prac-
tice is limited to his specialty of neurosurgery.
Doctor Smith is a member of the Alpha Omega
Alpha, the Rocky Mountain Neurosurgical Soc-
iety, the Society of Air Force Clinical Surgeons
and the Oklahoma State Neurosurgical
Society.

406

mained essentially free of pain. Two patients
required repeat procedures because of recur-
rent tic pain immediately after surgery. Reso-
lution of the pain was achieved with the re-
peated procedure.

DISCUSSION

The main advantage of the percutaneous
procedure is that it offers pain relief with low
morbidity and allows for precise lesion-
placement in any one or more of the three
trigeminal divisions. Utilizing graded and re-
peated lesions, the small, poorly-myelinated
pain-conducting C fibers can be destroyed leav-
ing the larger myelinated A and B fibers which
conduct pressure, some touch, and motor im-
pulses. Thus, the patient ideally achieves loss
of tic pain with preservation of touch, position,
and motor function to the jaw.

In all patients suffering from trigeminal
neuralgia, initial medical management is indi-
cated, consisting of a trial of Dilantin and/or
Tegretol. If side-effects are excessive or if
break-through pain occurs, then the patient
becomes a candidate for an alcohol injection of
the peripheral nerve at the supraorbital or
infraorbital foramen. If mandibular tic pain is
present or if the patient experiences recurrent
first or second division pain after an alcohol
block, then the electric tic procedure is indi-
cated.

The percutaneous tic procedure has greatly
reduced the need for craniotomy to control tic
pain. The low morbidity of the method provides
the possibility of repeating the procedure two
or three times if necessary to achieve pain re-
lief. In first division tic pain, the incidence of
corneal anesthesia and subsequent ulceration
is probably less with the percutaneous method
as some degree of corneal sensation can be
maintained.

SUMMARY

A safe, selective, low morbidity per-
cutaneous method of treatment for trigeminal
neuralgia has been introduced. The procedure
does not replace initial medical management
nor does it replace the office alcohol injection of
the supraorbital or infraorbital nerves for first
or second division pain. Although the follow-up
period is relatively short in the eight cases pre-
sented, the results should be comparable to re-
ported cases in the literature which achieve an

Oklahoma State Medical Association

approximate 90% incidence of tic pain
relief.5 7 □

Bibliography

1 Harris W: An Analysis of 1433 cases of paroxysmal trigeminal neuralgia
(trigeminal tic) and the end results of gasserian alcohol injection. Brain
63:209-224, 1940.

2. Hartel F: Die Behandlung der Trigeminusneuralgie mit intrakraniellen
alkoholeinspritzungen. Deutsch z Chir 126:429-552, 1914.

3. Jaeger R: Permanent relief of tic douloureaux by gasserian injection of hot
water. Arch Neurol Psychiat 77:1-7, 1957.

4. Jefferson A: Trigeminal root and ganglion injections using phenol in
glycerin for the relief of trigeminal neuralgia. J. Neurol Neurosurgery,
Psychiatry 26:345-352, 1963.

5. Kirschner M: Zur Elektrokoagulation des Ganglion Gasseri. Zentralbl
Chir 47:2841-2843, 1943.

6. Schurman M, Butz M, Brock M: Temporal retrogasserian resection of
trigeminal root versus controlled selective percutaneous electrocoagulation of
the ganglion of Gasser in the treatment of trigeminal neuralgia. Report on a
series of 531 cases. Acta Neurochir 26:33-53, 1972.

7. Sweet W, Wepsic J: Controlled thermocoagulation of trigeminal ganglion
and rootlets for differential destruction of pain fibers JNS 39:143-156 Feb
1974.

8. Tonis W, Kreissel H: Die Bedeutung einer sog faltigen Differientialdiag-
nose fur die chirurgische Behandlung der Trigeminusneuralgie. Deutsch Med
Wschr 76:1202-1205, 1951.

9. Turnbull I: Percutaneous rhizotomy for trigeminal neuralgia. Surgical
Neurology 2:385-389, 1974.

826 N.W. 11th Street, Oklahoma City, Oklahoma
73106

PULMONARY SYMPOSIUM

“Postoperative Pulmonary Problems”

Presented by

THE UNIVERSITY OF TEXAS
HEALTH SCIENCE CENTER AT HOUSTON

Medical School
and

Division of Continuing Education

March 19th-20th, 1976

This course will comprise an intensive review of the respiratory difficulties encountered by
practicing physicians in the care of surgical patients. It will include preoperative pulmonary evalua-
tion, pulmonary embolism prophylaxis and techniques of management of postoperative crisis, such
as atelectasis, pulmonary embolism, respiratory failure and the adult respiratory distress syn-
drome. One session will be devoted to the evaluation of patients for pulmonary resection.

The faculty will consist of guests and members of the departments of medicine, pathology and
surgery of The University of Texas Medical School at Houston. Active participation by the course
attendees will be encouraged in discussion of management challenges in individual case oriented
fashion.

For further information contact: The Office of the Director, The University of Texas Health
Science Center, Division of Continuing Education, P. O. Box 20367, Houston, Texas 77025
(713/792-4671).

Journal / November 1975 / Volume 68

407

Guidelines to Biopsy of the Breast

FRANK McGREGOR, MD
ARTHUR F. HOGE, MD
JOE M. PARKER, MD

Because of widespread and extensive
programs for early cancer detection,
physicians in this state are, and will continue
to be inundated with suspicious breast
findings, many without a palpable mass.
Diagnostic methods and approaches to biopsy

are discussed.

In the past few months Oklahoma’s physi-
cians have experienced a surge in requests for
breast examination because of the publicity
given to two of our nation’s most prominent
women. This initial surge is only the begin-
ning.

The Oklahoma Hospitals Breast Cancer
Control Program (OHBCC), one of the twelve
National Breast Cancer Demonstration Pro-
jects funded by the National Cancer Institute,
has as one of its major goals improvement in
detection and early diagnosis of breast cancer.
A massive program designed to "teach” breast
self-examination to women of Oklahoma over

Supported by: The National Cancer Institute under Contract Num-
ber NOl-CN-45137.

408

the age of sixteen has been launched. At this
time over 300 nurse-instructors have been
trained. More than 9,000 women have ex-
amined mannequins containing palpable
breast lumps and have learned to do self-
examination with some confidence. The
American Cancer Society has increased its lay
education program for the coming year. All of
this adds up to a surge of detection activity
and, it is hoped, a marked increase in the dis-
covery of early breast cancer.

Several hospitals in the state have estab-
lished screening clinics and at least fifteen
hospitals have thermographic, radiographic or
xeroradiographic equipment, hereinafter re-
ferred to collectively as mammography.

During the coming year it is anticipated that
some 6,000-8,000 women will present them-
selves to Oklahoma physicians with either a
breast lump or an abnormal finding detected
by screening center activities. These patients
may or may not have a dominant tissue mass,
nipple discharge, or skin changes suggesting
the location of a tumor mass. Many cases will
have none of these but only suspect calcific
flecks visualized on mammography or perhaps
a mass too small to be detected clinically.

Because of the anticipated increase in breast
biopsies we have prepared a guide to promote
efficiency in securing an accurate histologic
diagnosis with minimal risks and costs and
without harmful delay to the patient. Com-
plete unanimity of opinion and technique con-
cerning breast biopsy cannot be expected, but
certain principles of surgical practice are gen-

Oklahoma State Medical Association

erally accepted and will be outlined and dis-
cussed briefly.

Specific surgical techniques will vary from
surgeon to surgeon but preoccupation with
techniques should not obscure the importance
of obtaining adequate diagnostic tissue in a
form that is adequate for diagnosis by the con-
sulting pathologist.

INDICATIONS FOR BIOPSY

1. Palpable mass.

The presence of a clinically palpable mass
not attributable to anatomic variation or
physiologic change is the primary indication
for biopsy. With careful attention to breast
contour and consistency of a side-to-side com-
parison, the experienced physician will learn
to distinguish the gross cyst amenable to aspi-
ration from the solid mass requiring biopsy.
Specific stigmata of cancers, such as skin dim-
pling or nipple retraction may further aug-
ment the indication for biopsy.

2. Gross cysts.

The finding of a smooth, ovoid or speherical
mass, movable, firm or fluctuant, is an ade-
quate indication for attempted aspiration. This
procedure can permit immediate differentia-
tion of gross cysts and solid tumor. Accepted
practice requires open biopsy for masses not
completely decompressed by aspiration, for re-
current cysts, and upon aspiration of bloody
fluid.

3. Nipple discharge.

Spontaneous nipple drainage from non-
lactating breasts is an indication for cytologic
study even though the "false-negative” rate
may be high. Lactation may occur in non-
puerperal states and the cause should be ascer-
tained. Non-lactating nipple drainage should
be investigated by a careful examination and
location of the duct system involved, mammog-
raphy, and possibly thermography. In the ab-
sence of a palpable mass or mammographic
localization of suspect areas, total major duct
excision may be necessary. Pink or frankly
bloody discharge, particularly in the presence
of a mass, is an absolute indication for surgery
with removal of the major duct system in-
volved.

4. Non-palpable lesions.

Becoming increasingly common today is the
finding of an abnormal pattern on mammog-
raphy in the absence of a palpable mass. If
these areas contain any of the stigmata charac-
teristic of malignancy (a stellate or irregular
mass, abnormal calcification, skin thickening),

there is very high percentage correlation with
positive histologic diagnosis. Suspicious le-
sions other than characteristic stigmats should
lead to repeat mammography and screening at
three months.

5. Eczematoid changes of the nipple or
areola.

Chronic irritative or ulcerative skin changes
of the nipple or areola suggestive of Paget’s
disease should be considered an indication for
mammography. In the absence of a palpable
mass or mammographic abnormality the nip-
ple or areola should be biopsied. If evidence of
underlying changes in the duct system is pres-
ent, the biopsy of the skin should be accom-
panied by extensive biopsy of the duct system
in question.

6. Axillary adenopathy.

Occult breast cancer should be considered as
a possible cause of any significant axillary
node enlargement. After careful evaluation for
other causes, including metastatic cancer from
more distant sites, biopsy of the node may be
necessary to determine an accurate diagnosis.

Frank McGregor, MD, graduated from the
University of Oklahoma College of Medicine
where he is now Clinical Professor of Surgery
and is Vice-President of Medical Staff Affairs
and Director of Medical Education at Baptist
Medical Center of Oklahoma . Doctor McGregor
is President of the American Cancer Society,
Oklahoma Division, Inc., a Fellow of the Ameri-
can College of Surgeons and Past-President of
the Oklahoma Chapter of the American College
of Surgeons.

Arthur F. Hoge, MD, was graduated from
Tulane University School of Medicine and is
presently Assistant Professor of Research Medi-
cine at the University of Oklahoma Health
Sciences Center and an Assistant Member of the
Oklahoma Medical Research Foundation. Doc-
tor Hoge is a member of the American Society of
Clinical Oncology, the American Association
for Cancer Research, the Southwest Oncology
Group, the American College of Obstetrics and
Gynecology and the Southwestern Surgical
Congress.

Since his graduation from Washington Uni-
versity School of Medicine, Joe M. Parker, MD,
has been certified by the American Board of
Surgery. Among his medical affiliations are the
American College of Surgeons and the South-
western Surgical Congress.

Journal / November 1975 / Volume 68

409

Biopsy / McGREGOR et al

Mammography should be done prior to the
node biopsy. Normal mammograms do not rule
out the existence of an occult breast cancer.

GENERAL RULES

Representative tissue from all suspected le-
sions should be obtained. This may include all
of a small lesion or a part of a large lesion. If
the original specimen does not reflect the find-
ings of either physical examination or mam-
mography, additional tissue should be ob-
tained.

Non-invasive mammography should be per-
formed on all patients with palpable masses
which are suspected of being malignant in
order to identify other non-palpable lesions.
This is particularly true in those patients who
are at high risk for cancer. If the mammo-
graphic findings are suggestive or diagnostic of
malignancy, one should consider doing all
metastatic surveys prior to subjecting the pa-
tient to a biopsy and immediate radical mas-
tectomy, as a significant number of patients
will have metastatic disease at that time.

Specimen Radiography: All specimens in
which abnormal calcifications or other mam-
mographic evidence of disease is the only indi-
cation for biopsy should be submitted to
radiography prior to examination by the
pathologist. If the specimen-radiography does
not reveal the findings noted on mammog-
raphy further tissue removal should be done.
The pathologist should have both the
specimen-radiography and the mammogram
prior to sectioning and blocking the specimen.

BIOPSY METHODS

1. Needle aspiration of the cyst.

Aspiration of a clinically-suspected cyst may
be undertaken in an out-patient setting using
local anesthesia. Stabilizing the mass between
the fingers of one hand, the operator may insert
a #20 or a #21 gauge needle for aspiration of
the cyst fluid. If a larger needle is used, it may
be necessary to puncture the skin with a sharp
pointed scalpel blade to facilitate insertion of
the needle. Cytologic analysis of the cyst fluid
should be obtained but is not a reliable indica-
tion of malignant change within the breast ex-
cept in the unusual occurrence of an intracystic
carcinoma. The presence of bloody fluid, even

410

in the absence of equivocal cytologic findings,
is an indication for open biopsy. A residual
mass lesion after aspiration, and recurrent
cysts are also indications for open biopsy.

2. Biopsy of solid masses.

Needle aspiration of a solid mass can be done
in an out-patient setting but is not generally
recommended except to confirm obvious
cancer. A "negative” needle biopsy should not
be interpreted as anything but an indication
for open biopsy. One established method in-
volves use of a #18 needle attached to a 10 cc or
20 cc syringe. After insertion of the needle into
the mass, suction is applied to the syringe as it
is advanced and retracted frequently enough to
dislodge and mince a small amount of tissue for
removal. Macerated tissue thus removed
within the needle or syringe is placed on slides
for smears or in a fixative fluid for histologic
sections. Alternately, a biopsy needle such as
the Vim-Silverman needle can be used to ob-
tain tissue for histologic study, In any method
of needle biopsy, the diagnosis of a non-malig-
nant lesion cannot be accepted as the final
diagnosis. Despite the possibility of not estab-
lishing a diagnosis of malignant disease in
some instances, needle biopsy is a valuable aid,
particularly in the inoperable patient who is to
receive some sort of palliative therapy. If
undertaking needle biopsy in a setting where
the method is not frequently used, the surgeon
should discuss the form of material and pre-
ferred fixative with the pathologist before-
hand.

3. Incisional biopsy.

In the operating room under local or general
anesthesia, large tumors can be biopsied by
removing a small wedge for frozen or perma-
nent section. This is a preferred technique for
large tumors to avoid undue disruption of the
breast, while tumors less than three cm in
diameter may be completely removed without
difficulty. If the diagnosis is suggestive of in-
situ cancer or well differentiated tubular car-
cinoma, definitive therapy should be postponed
until a thorough study has been made with
permanent sections. If the frozen section diag-
nosis is undifferentiated carcinoma, the
surgeon would be well advised to postpone de-
finitive therapy until a metastatic survey has
been completed. If the frozen section diagnosis
is that of invasive ductal carcinoma, the deci-
sion as to definitive surgery under the same
anesthetic should be made by the surgeon. If
the lesion is large, if any of the grave signs of

Oklahoma State Medical Association

malignancy are noted, or if the nodes are
thought to be clinically malignant, it may be
advisable to postpone surgery until metastatic
surveys have been completed.

4. Excisional biopsy.

Under this general heading are included
segmental and quadrant biopsies undertaken
for small masses, usually less than three cm in
size. The type of skin incision may vary as a
matter of personal preference, but most
surgeons feel that a circumferential incision
leaves a more cosmetic scar. Following expos-
ure of the glandular surface of the breast, the
peripheral edge of the specimen to be removed
is mobilized and elevated from the underlying
chest wall. Using this maneuver, the surgeon
may then palpate both the deep and superficial
surfaces of the gland simultaneously, facil-
itating the localization of small or elusive le-
sions. Even with a lesion thought to be benign,
adjacent tissue should be included for better
assessment of the normal breast. With non-
palpable lesions found on mammography, a
wide segmental biopsy may be necessary to as-
sure inclusion of the lesion, since the
radiologist’s localization of the lesion may be
altered by the patient’s position on the operat-
ing table. In time, other methods of localization
such as insertion of needles with the aid of
fluoroscopy and mammography may reduce
the need for wide excision to assure removal of
such lesions.

A small lesion that is centrally located may
be excised through a circum-areolar incision.
Deep V-shaped incisions encompassing the
mass may be closed in layers to re-establish
contour and to allow an adequate base for the
overlying areola. Such an incision may be used
for major duct system excision. In all breast
excisional biopsies, particularly those for small
lesions, subcutaneous fat can be preserved on
the skin flaps to facilitate later closure. With
approximation of breast tissue in several
layers and careful placement of the thick skin
flaps, normal breast contour should be estab-
lished. In large excisions the breast size may be
reduced but breast contour should not be dis-
torted.

The tremendous interest in cancer and par-
ticularly that focused on breast malignancies
can be very rewarding if this interest can be
directed toward earlier diagnosis. The ac-
tivities of the Breast Cancer Control Network,
the Breast Cancer Screening Centers, and the
American Cancer Society are causing a
marked increase in the number of women seek-
ing physician guidance. We hope this guide
will help physicians determine the indications
for biopsy and logical procedural steps. □

Address for reprints:

Arthur F. Hoge, MD, 825 NE 13th Street, Oklahoma
City, Oklahoma 73104

HEMATOLOGY-ONCOLOGY

CONFERENCE

Hillcrest Medical Center 12 Noon Gold Room, Rehabilitation Center

This conference has been approved for credit on an hour-for-hour basis in Category
1 for the Physicians’ Recognition Award of the American Medical Association. The
program is also acceptable for one prescribed hour by the American Academy of Family
Physicians.

These courses essentially provide a review of all important topics in the broad fields
of oncology and hematology over a year’s time. Topics include:

November 21st — Anemia and Renal Failure
December 5th — Skin Cancer
December 12th — Clinical Anticoagulation
December 19th — Remote Effects of Neoplasms

Journal / November 1975 / Volume 68

411

Congenital Anomalies In Infants And

Children, 1875

RONALD D. GREENWOOD, MD

In 1875, the diagnosis and treatment of
congenital anomalies was very limited.
Knowledge in this area and descriptions from

a century ago are reviewed.

One hundred years ago the outlook for the
infant born with congenital anomalies or for
the child with congenital disease was bleak in-
deed. In the ensuing century, the developments
in this area have been particularly rapid. In
1875, pediatrics was in its infancy, Virchow’s
Cellular Pathology (1858) and Darwin’s Origin
of the Species (1859) were new on the scene.
There were only a dozen hospitals in this coun-
try devoted solely to the care of children.
Abraham Jacobi (1830-1919) had come to New
York in 1853 and was serving in a pediatric
post (1860) at the New York Medical College.
Thomas Morgan Rotch (1849-1914) had
graduated from Harvard just one year before
and would 13 years later (1888) hold the first
Professorship of Pediatrics at Harvard. Luther

The Children’s Hospital Medical Center and Department of Pediatrics, Har-
vard Medical School, Boston, Massachusetts

412

Emmet Holt and Issac Arthur Abt, giants in
American Pediatrics, were very young men.
O’Dwyer, likewise, was working in New York
but had not yet performed intubation. In Eng-
land, Charles West (1816-98) had established
the Children’s Hospital at Great Ormond
Street in London and resigned in 1875. Henri
Louis Roger (1809-91), Ernest Bouchet
(1818-91), and Marie-Jules Parrot (1839-83)
were practicing medicine in France. In another
European center, Henoch (1820-1910) had re-
cently described the infantile purpura; Otto
Soltmann, Alois Bednar, Carl Hennig, Alfred
Vogel, Johann H. Rehn, Carl Gerhardt, Jo-
hann T. A. Steffen, Phillip Biedect, and others
were current practitioners of medicine for chil-
dren.

Infants and children with congenital
anomalies were usually felt to be untreatable.
Ether had been introduced only 30 years before
at the Massachusetts General Hospital on Oc-
tober 16, 1846, and aseptic surgery was in its
infancy. Medical therapy was likewise very
primitive.

In 1875, the malformations known were
markedly fewer in number than today but
most gross major system anomalies were
known. Only a few of the syndromes or pat-
terns of malformations today known by their
eponyms were noted by 1875 (Table 1). Also
noted were: congenital epulis (noted in 1871) is
sometimes called Neumann Syndrome after
Ernst Neumann (1843-1918); Prune Belly
Syndrome was first noted in 1839 by F. Froh-

Oklahoma State Medical Association

lich but is only rarely associated with his
name; cleft lip, palate, fistula of lower lip and
progeria facies were noted in 1845 and 1862 by
Jean N. Demarquay (1811-1875) and Didier
Dominique Alfred Richet (1816-1891) respec-
tively, but Demarquay-Richet Syndrome has
only rarely been used.

We shall consider the descriptions in 1875 of
a few of the more serious congenital malforma-
tions.

Gross malformations of the body in general,
"double monsters” or "attached fetal remains”
were usually not treatable. Some forms were
amenable to surgery. As Holmes reported:

No difficulty of diagnosis can exist in the
case of the attached parasite. The advantages
and the feasibility of removing it from the
body to which it is appended will depend in a
great measure upon the place and extent of its
attachment, and partly upon the nature of the
parasite itself.

Imperforate Anus (described by Holmes):

Imperforate rectum is a deformity which,

though sufficiently rare to prevent most prac-
titioners from having much individual ex-
perience of it, is yet common enough to cost the
lives of many children every year . . .

Cases of imperforate rectum may be divided
into two classes, vis. those in which no anus
exists (imperforate anus properly so called)
and those in which there is an anus leading
into a cul-de-sac (imperforate rectum) . . .

Membranous imperforate anus was amen-
able to surgical intervention.

When bulging is perceived, all that is neces-
sary is to make an incision of sufficient size in
the situation of the natural anus, and give exit
to the contents of the gut.

When there was complete or partial absence
of the rectum, surgery was far more difficult.

When no bulging is perceived, after waiting
for a reasonable time, it is probable that the
lower end of the rectum is deficient. In such a
case, if the external parts exhibit no obvious
malformation, an exploratory operation
should be performed, the object of which is to
discover the end of the rectum, and if possible

Table 1

CONGENITAL SYNDROMES OR ANOMALIES KNOWN
IN 1875 WHICH TODAY ARE RECOGNIZED BY THE NAMES OF THEIR DISCOVERER

Vincent Alexander Bochdalek
(1801-1883)

Left Congenital Diaphragmatic
Hernia

1848

Giovanni Battista Morgagni
(1682-1771)

Anterior Diaphragmatic
Hernia

1761

John Langdon Haydon Down
(1828-1896)

Mongolism

1866

Guillaume Benjamin Amand Duchenne
(1806-1875)

Muscular Dystrophy

1868

Wilhelm Heinrich Erb

(1840-1921)

Upper Arm Paralysis

1874*

Wilhelm Ebstein

(1836-1912)

Downward Displacement of
Tricuspid Valve

1866

Nicolaus Friedreich

(1825-1882)

Friedreich’s Ataxia

1863

Gustav Scheuthauer

(1832-1894)

Cleidocranial Dysostosis

1871

John Zachariah Laurence
(1830-1874)

Laurence Moon Biedl Syndrome

1866

Moritz Heinrich von Romberg
(1795-1873)

Facial Hemiatrophy

1846

Ernst Munchmeyer

Myositis Ossificans

1869

(1846-1880)

*Also described by Duchenne in 1875

Journal / November 1975 / Volume 68

413

Anomalies / GREENWOOD

to draw it down, and attach it to the skin in the
situation of the anus.

Patients with fistulae, especially, to the vag-
ina, often were spared surgery. Holmes notes
one patient:

. . . woman was discovered on rectal
examination to have imperforate anus, the
rectum opening obliquely into the back of the
vagina. In this case, the command over the
feces was so perfect that no inconvenience re-
sulted; and neither she, nor her husband, nor
the accoucheur who had delivered her three
times were aware that there was any peculiar-
ity about the sexual organs. Such cases as
these should not be interfered with.

Gastrointestinal Obstruction

Congenital obstruction elsewhere in the gas-
trointestinal tract was a most serious problem.

Colotomy in congenital obstructions of the
lower bowel: When the rectum is entirely de-
ficient, the only means of preserving life is to
open some higher part of the bowel.

Obstruction of the small intestine was
recognized clinically but much less frequently.
Surgery was often attempted but as Holmes
noted "little hope can be entertained of good
from anything.”

Spina bifida was a severe anomaly. Chaus-
sier determined that it occurred once in one
thousand births.

Spina Bifida was rarely seen at the
Children’s Hospital in Boston. Treatment was
unsatisfactory. A shield was constructed to "re-
lieve pressure and prevent chafing, unless the
meningocele will inevitably rupture.”

Vogel noted:

Surgeons h^ave tried countless varieties of
methods with the hope of bringing about a
diminution of the tumor and closure of the
spinal canal. The almost invariable failure of
all surgical procedures is due to the fact that
the inner wall of the sac is formed by the spin-
al membrane and that any injury of this mem-
brane is apt to produce meningitis which can-
not be limited to the sac. The tumor has been
repeatedly punctured with exploring trocars
and pierced with needles often forming valvu-
lar openings in the integument. Lately Gaupp
presented a boy seven years old, who had a
hydrorachis the size of a child’s head, which he
had cured in the first few weeks of infantile
life by puncturing it eight times. After the

414

first puncture, the fissure of the vertebrae
could be distinctly felt, but the gap rapidly
diminished, and finally closure took place in
ten weeks. All the parts constituting the
vertebrae are now present in this boy, but the
spinous processes are somewhat flattened. Ex-
cision, with the subsequent use of compression
by quills or small wooden rods, has been tried.
Chassaignac treated these cases by puncture
and injecting iodine, as in a hydrocele, and the
pediculated variety has been tied off. Finally,
constant steady pressure upon the tumor by a
hair pillow has been tried, but, although this
method caused great pain and convulsive
twitchings, it did not effect a single cure. All
experimenters have been obliged to acknowl-
edge that their efforts have failed, now still
more, that meningitic symptoms, which are
always followed by death, came on immediate-
ly after the operation. Though the prognosis of
hydrorachis is at best very unfavorable, most
children dying even without operation, still,
owing to the rarity of this condition, statistics
upon this point are scarce, and it is therefore
difficult to determine which of the two courses
it is best to pursue. The most rational treat-
ment . . . is to protect the sac from all kinds of
injury and pressure, by a soft, cup shaped pad
which will only rest upon its margin, and
which is secured to the body by elastic straps.

If the hydrorachis is complicated with con-
genital hydrocephalus, as is frequently the
case, then no other means should be adopted
than that just described, for every diminution
and compression of the tumor causes tension
within the head.

Cleft Lip and Palate
Vogel described this anomaly:

Harelip is a congenital splitting of the upper
lip; cleft palate, a congenital fissure of the
hard palate . . . Nothing but an operation can
remedy this deformity. As regards the time
when it is to be performed, much has already
been written and disputed ... At all events,
however, the operation should be performed
before the eruption of the teeth, for, as soon as
dentition has once begun, children are oftener

Since his graduation from the Northwestern
University Medical School in 1969, Ronald D.
Greenwood, MD, has been certified by the
American Board of Pediatrics. His practice is
limited to his specialty, pediatric cardiology . In
addition, he is affiliated with the Departments
of Pediatrics and Anatomy at Harvard Medical
School. He is a member of the American
Academy of Pediatrics and the American As-
sociation for the History of Medicine.

Oklahoma State Medical Association

subject to sickness, and on that account the
result often proves a failure. Moreover, chil-
dren more than six months old begin to use
their hands, with which they may tear down
the plaster after the operation, or entangle
them among the points of the pins, and thus
frustrate its success.

Surgical details for those lesions amenable
to surgery are not discussed, but we should
briefly look at the approach to cleft lip to have
a feeling for surgical methods.

Before the operation, the child is to be kept
awake for several hours, in order that it may
subsequently fall into a deeper sleep than
usual; and it is also to be nursed so that thirst
or hunger may not rouse it too soon. It is best
to wrap the entire body up to the neck in a
sheet, and then place it in the lap of an assis-
tant. Nothing more is necessary for the opera-
tion than a sharp tenaculum, strong sharp sci-
ssors, the sewing apparatus, and a few strips of
adhesive plaster. A second assistant now
seizes a part of the split lip between his thumb
and index-finger and compresses the vessels.

■ The operator, seated opposite the child, seizes
hold of the border of the lip with the
tenaculum where it passes over into the fis-
sure upwardly, pushes the scissors into the
slit, and with one cut removes the entire edge.
The same maneuvers are repeated on the
other side. After the edges have been adjusted,
two or three needles, the lower ones first, are
introduced, and a few turns of the ligature
taken around each one of them.

Renal anomalies were often well tolerated
and thus not discovered.

Vogel reported:

The kidneys are never totally absent; even
in the most incomplete abortions they may be
detected in some form. One kidney only is to be
found in some cases, in which condition
Rokitansky makes a distinction between the
single and the simple. In the former, a single
kidney is found at the normal place, to the
right or left side of the vertebrae column, dif-
fering in shape but little from the ordinary

kidney, while on the opposite side there is no
trace of a gland. The simple kidney, on the
other hand, is an abnormal fusion of the two
kidneys, the most common form of which is the
horshoe kidney.

Genitourinary anomalies: Hypospadius and
epispadius were well understood and surgery
was not considered. Exstrophy, however, was a
more severe anomaly. Vogel describes the
situation:

In all instances the patients afflicted with it
generate a disgusting urinary odor and suffer
from constant excoriations around the open-
ings of the ureters . . . There is nothing in
these deformities incompatible with life and
cases are known where the persons attained
an age of even forty years. Indeed, Huxam de-
scribes the very remarkable case of a woman
wdio, afflicted with this prolapsus vesicae con-
genitus and cloacae married in her twenty-
third year, conceived, and gave birth to chil-
dren. The husband of such a creature deserves
almost as much admiration as herself.

Malformations such as congenital heart dis-
ease, omphalocele, esophageal atresia, and
congenital diaphragmatic hernia were serious
anomalies that were also recognized but were
not amenable to intervention. □

ACKNOWLEDGEMENT

The Francis A. Countway Library of Medicine,
Harvard Medical School, provided the historical ma-
terials on which this review was based.

BIBLIOGRAPHY FOR FURTHER READING
ON DISEASE DESCRIPTIONS:

Vogel, A. (Trans, and Ediby, Raphael, H.): A Practical Treatise on the Dis-
eases of Children. New York, D. Appleton and Company, 1871.

Holmes, T.: A System of Surgery, New York, William Wood and Co. 1875
(Vol. 5).

300 Longwood, Boston, Massachusetts 02115

Remember these dates —

May 6th, 7th, 8th, 9th, 1976
OKLAHOMA MEDICAL SUMMIT ’76

Lincoln Plaza Forum
Oklahoma City, Oklahoma

Journal / November 1975 / Volume 68

415

Intrauterine Infection, 1808

RONALD D. GREENWOOD, MD

At one of the early meetings of the Medical
and Chirurgical Society of London, Doctor
Edward Jenner related an instance of
smallpox in the newborn of a newly
vaccinated woman. This is probably the
earliest case of fetal infection due to
maternal treatment

In 1805, a few physicians and surgeons in
London met for the purpose of forming a so-
ciety "founded upon liberal and independent
principles, and conducted with the propriety
and dignity which are worthy of the medical
profession.” The result was the Medical and
Chirurgical Society of London. Members in-
cluded John Abernathy, Matthew Baillie,
Humphrey Davey, John Richard Farre, John
Hunter, Edward Jenner and John Sims. Many
other prominent physicians were members. In
1809, the council President was Matthew Bail-
lie. In that year the first volume Medico-
Chirurgical Transactions appeared; these were
the papers read at meetings of this society.

At such a meeting on April 4, 1809, Edward
Jenner read a paper entitled "The Cases of
Small-Pox Infection communicated to the

416

Foetus in Utero Under Peculiar Circumstances
with Additional Remarks.”

This included a most interesting medical
discovery although it was poorly understood at
the time. Jenner relates a case of Mr. Henry
Gervis, a surgeon at Ashburton in Devonshire.

The smallpox having appeared in the
Village of Woolson Green, about three
miles from Ashburton, on the 6th of May,
1808, 1 vaccinated a poor woman . . . who
was in the last month of her pregnancy.
Her three children had been innoculated
the preceding day with variolous matter
... I made two punctures in each arm,
each of which fortunately succeeded, and
they regularly passed the disorder, com-
plaining only on the tenth and eleventh
day, when the areola was most extended
as is usual. I saw her very frequently dur-
ing the progress of her disorder, and once
or twice after its complete termination: I
therefore can speak positively, that dur-
ing that time she laboured under no
symptom but what is connected with the
cowpox. From this period she continued
perfectly well, and on Saturday last the
11th instant, she was delivered of a
female child, having at the time of its
birth many eruptions on it, bearing much
the appearance of small-pox in the early
stage of the disease. This even happened
five weeks after her vaccination, and one

Oklahoma State Medical Association

month after she had been exposed to the
variolous infection of her own three chil-
dren, and that of several other persons in
the same village. On the 14th I visited the
child again, when I found the eruptions
had increased to some thousands, per-
fectly distinct, and their character well
marked ... on the 18th the infant was

seized with slight convulsions, and on the
morning of the 19th it expired.

In addition to the circumstance of the
mother’s conveying the variolous infec-
tion to her unborn child, without feeling
any indisposition from its action on her
own constitution, I must remark that
there cannot be a stronger proof of the
efficacy of vaccine innoculation than this
case affords.

ACKNOWLEDGEMENT

I am indebted to the Francis A. Countway Library
of Medicine Harvard Medical School for use of his-
torical materials.

REFERENCE

Jenner, E.: Two Cases of Small-Pox Infection Communicated to the Foetus in
Utero Under Peculiar Circumstances with Additional Remarks. Medico-
Chirurgical Transactions 1:269-275, 1809.

300 Longwood, Boston, Massachusetts 02115

SELECTED TOPICS IN CARDIOLOGY

presented by

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON

Division of Continuing Education

December 2nd, 3rd and 4th, 1975

This program will present an intensive review in cardiology. Some of the topics to
be included in the program are: (1) New Concepts of Pathogenesis and the Clinical
Significance of T-wave Abnormalities (2) A Rational Approach to Therapy of Ar-
rhythmias (3) Arrhythmias in Coronary Artery Disease (4) ECG in the Absence of
Heart Disease.

The guest lecturer will be Borys Surawicz, MD, Professor of Medicine, University of
Kentucky College of Medicine, Lexington, Kentucky.

For further information write: The Office of the Director, The University of Texas
Health Science Center at Houston, Division of Continuing Educaton, P.O. Box
20367, Houston, Texas 77025.

Journal / November 1975 / Volume 68

417

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in spite of an initial response to Nalline ® (nal-
orphine HCI) or Narcan ® (naloxone HCI) or
may be evidenced as late as 30 hours after in-
gestion. LOMOTIL IS NOT AN INNOCUOUS
DRUG AND DOSAGE RECOMMENDATIONS
SHOULD BE STRICTLY ADHERED TO, ESPE-
CIALLY IN CHILDREN. THIS MEDICATION
SHOULD BE KEPT OUT OF REACH OF
CHILDREN.

Indications: Lomotil is effective as adjunctive ther-
apy in the management of diarrhea.

Contraindications: In children less than 2 years,
due to the decreased safety margin in younger age
groups, and in patients who are jaundiced or hyper-
sensitive to diphenoxylate HCI or atropine.

• DESIGN

• OFFICE SUPPLIES

• PERSONAL SERVICES

• MEDICAL EQUIPMENT

• PERSONNEL HIRING
& TRAINING

• LEGAL SERVICES

• FINANCIAL SERVICES

• TAX CONSULTING

medical practices, inc.

Glenbrook Centre-West

1140 N.W. 63rd • Suite 100 • Oklahoma City, OK 73116

L 405 843-5581 A

• INSTALLATIONS

• OFFICE EQUIPMENT

• PUBLIC RELATIONS

• INSURANCE SERVICES

• ACCOUNTING SERVICES

• HOME &

OFFICE LOCATING

• CONTINUING
MANAGEMENT LIAISON

SIXTH ANNUAL

ASPEN RADIOLOGY COMMITTEE

The sixth annual Aspen Radiology Conference
will be held March 1st-5th, 1976, at the Aspen
Institute for Humanistic Studies, Aspen, Col-
orado. The conference is designed for physi-
cians and scientists interested in diagnostic
radiology, nuclear medicine and radiation
therapy and will explore the impact of clinical and
technological advances on radiologic practice.

The topics for discussions will include ad-
vances in cardiovascular, gastrointestinal, bone
and neuroradiology involving a tri-radiological
approach. Each morning will survey the ad-
vances in a single radiology subdivision as a re-
fresher course with independent parallel diag-
nostic, nuclear medicine and therapy sessions.
Instructive cases, illustrating these topics and
previewed by the audience, will be presented for
open discussion in the afternoons.

Further information may be obtained from
Emanuel Salzman, MD, Conference Chairman,
Division of Radiology, Beth Israel Hospital, De-
nver, Colorado 80204.

Warnings: Um with special caution in young chil-
dren, because of variable response, and with extreme
caution in patients with cirrhosis and other ad-
vanced hepatic disease or abnormal liver function
tests, because of possible hepatic coma. Diphenoxy-
late HCI may potentiate the action of barbiturates,
tranquilizers and alcohol. In theory, the concurrent
use with monoamine oxidase inhibitors could pre-
cipitate hypertensive crisis. In severe dehydration
or electrolyte imbalance, withhold Lomotil until cor-
rective therapy has been initiated.

Precautions: Addiction (dependency) to diphenoxy-
late HCI is theoretically possible at high dosage. Do
not exceed recommended dosages. Administer with
caution to patients receiving addicting drugs or
known to be addiction prone or having a history of
drug abuse. The subtherapeutic amount of atropine
is added to discourage deliberate overdosage;
strictly observe contraindications, warnings and pre-
cautions for atropine; use with caution in children
since signs of atropinism may occur even with the
recommended dosage. Use with care in patients with
acute ulcerative colitis and discontinue use if ab-
dominal distention or other symptoms develop.

Dosage and administration: Lomotil la contraindi-
cated in children leas than 2 years old. Use only
Lomotil liquid for children 2 to 12 years old. Forages
2 to 5 years, 4 ml. (2 mg.) t.i.d.; 5 to 8 years, 4 ml.
(2 mg.) q.i.d.; 8 to 12 years, 4 ml. (2 mg.) 5 times
daily; adults, two tablets (5 mg.) t.i.d. to two tablets
(5 mg.) q.i.d. or two regular teaspoonfuls (10 ml.,
5 mg.) q.i.d. Maintenance dosage may be as low as
one fourth of the initial dosage. Make downward
dosage adjustment as soon as initial symptoms are
controlled.

Overdosage: Keep the medication out of the reach
of children since accidental overdosage may cause
severe, even fatal, respiratory depression. Signs of
overdosage include flushing, hyperthermia, tachy-
cardia, lethargy or coma, hypotonic reflexes, nystag-
mus, pinpoint pupils and respiratory depression
which may occur 12 to 30 hours after overdose. Evac-
uate stomach by lavage, establish a patent airway
and, when necessary, assist respiration mechani-
cally. A narcotic antagonist may be used in severe
respiratory depression. Observation should extend
over at least 48 hours.

Dosage forms: Tablets, 2.5 mg. of diphenoxylate HCI
with 0.025 mg. of atropine sulfate. Liquid, 2.5 mg. of
diphenoxylate HCI and 0.025 mg. of atropine sulfate
per 5 ml. A plastic dropper calibrated in increments
of Vz ml. (total capacity, 2 ml.) accompanies each
2-oz. bottle of Lomotil liquid.

Searle & Co.

San Juan, Puerto Rico 00936

Address medical inquiries to:

G. D. Searle & Co.

Medical Department, Box 5110,

Chicago, Illinois 60680 455

SEARLE

418

Oklahoma State Medical Association

The Cost of Hospitalization
Oklahoma Hospitals

JAMES E. PERRY, MBA

Given the increasing cost of hospitalization,
Oklahoma hospitals exhibit a wide range of
operating characteristics.

Within the United States, significant con-
cern has been expressed with respect to the ris-
ing costs of goods and services in many sectors
of the economy. One area of concern which has
received considerable attention to date, and
will apparently continue to receive attention in
the foreseeable future, is our health care deliv-
ery system.

The health care industry in the United
States has grown continuously, to the point,
whereby hospital expenditures alone in recent
years have accounted for more than 2.8% of the
Gross National Product.1 Whereas hospital re-
lated expenditures totaled $12.0 billion in
1964, by the end of 1973 this figure had risen to
$36.3 billion, an increase of over 300%2 As
greater amounts of money are expended in the
delivery of health care, pressures, too, for cost

Journal / November 1975 / Volume 68

control and institutional efficiency on the one
hand, and the development of alternative
methods of delivery, on the other hand, have
arisen. While the cost of hospitalization is only
a component part of the total cost of health
care, albeit large, a review of the operational
characteristics of hospitals, focusing primarily
on the overall per diem cost of hospitalization
illustrates the significance of the health prob-
lem facing the nation today.

HOSPITAL SERVICE CHARACTERISTICS

Latest information compiled and released by
the American Hospital Association indicates
that in the state of Oklahoma there are 145
hospitals with a total of 17,789 available beds.3
These hospitals had an average occupancy rate
of 72.5%, accounted for 477,833 admissions,
4,707,950 inpatient days of care, and over 2.3
million outpatient occasions of service.4 A
complete breakdown of hospitals, beds, ad-
missions, occupancy, inpatient days, and out-
patient visits, by hospital bed size and hospital
type is presented in Tables 1 and 2 respec-
tively.

While the 125 hospitals with an average bed
size of less than 199 beds control 44.5% of the
total beds available and account for 58.8% of
all admissions, they account for only 39.4% of

423

Hospitalization / PERRY

TABLE 1

State of Oklahoma

Hospitals, Beds, Admissions, Occupancy, Inpatient Days,
Outpatient Visits by Hospital Bed Size

Classi-
fication Hospitals

Beds

Admissions

Occupancy

Inpatient

Days

Outpatient

Visits

6 -24 beds

202

5,780

47.0

35,528

16,774

25 -49 beds

1,723

53,840

56.2

352,792

330,245

50 -99 beds

2,973

101,454

61.4

667,131

588,164

100-199 beds

3,011

120,111

72.8

799,845

251,790

200-299 beds

1,951

55,805

74.3

528,762

646,669

300-399 beds

692

23,768

79.6

201,330

56,310

400-499 beds

892

23,807

77.6

252,599

231,379

500 & over

6,345

93,268

80.8

1,869,963

234,922

Total

145

17,789

477,833

72.51

4,707,950

2,356,253

Weighted Average

Source: American Hospital Association, Hospital Statistics 1974 Edition
(Chicago, Illinois, 1974), p. 128.

all inpatient days and 50.4% of outpatient vis-
its. The remaining 20 hospitals with an aver-
age bed size greater than 200 beds control
54.6% of total inpatient days and 49.6% of out-
patient occasions of service. In fact the eight
largest hospitals account for almost 40% of
total inpatient days. These same hospitals ac-
count for approximately 10% of outpatient vis-
its, thus bearing out the expectation that the
largest hospitals, located within metropolitan
areas, possessing sophisticated labor and capi-
tal intensification, generally, but certainly not

exclusively, respond to the more acute illnes-
ses, necessitating longer periods of hospitaliza-
tion. Furthermore, their outpatient activity
derives basically from the fundamental re-
sponsibility to offer a full range of medical ser-
vice to the community, rather than a conscious
effort to cultivate this aspect of the health care
market.

HOSPITAL OPERATING CHARACTERISTICS
While hospital service characteristics, as

TABLE 2
State of Oklahoma

Hospitals, Beds, Admissions, Occupancy, Inpatient Days,
Outpatient Visits by Hospital Type

Type Hospitals

Beds

Admissions

Occupancy

Inpatient

Days

Outpatient

Visits

Psychiatric

Tuberculosis

4,248

10,447

81.4

1,262,538

73,128

& Other Resp.

150

347

51.3

28,144

1,058

Maternity

125

16.7

871

667

Rehabilitation

578

93.5

26,278

253

Orthopedic

2,625

82.4

22,277

6,803

Chronic

231

1,054

83.5

70,450

689

General

133

12,997

462,657

69.5

3,297,395

2,273,655

Total

145

17,789

477,833

72.51

4,707,950

2,356,253

xWeighted Average

Source: American Hospital Association, Hospital Statistics 1974 Edition
(Chicago, Illinois, 1974), p. 128.

424

Oklahoma State Medical Association

TABLE 3

Oklahoma Community Hospitals
As A Per Cent of State Hospital Population
by Hospital Bed Size

All Community

Oklahoma Community Hospitals

Classification Hospitals Hospitals Per Cent To Total

6 - 24 beds

90.0

25 - 49 beds

88.0

50 - 99 beds

80.0

100-199 beds

95.0

200-299 beds

50.0

300-399 beds

100.0

400-499 beds

50.0

500 & over

50.0

Total 145 119 82.1

Source: American Hospital Association, Hospital Statistics
1974 Edition (Chicago, Illinois, 1974), p. 128.

cited above, shed light on the magnitude of the
health care delivery system in Oklahoma, a
review of the operational characteristics of
Oklahoma hospitals serves to focus on the cost
significance of the health care process. For the
purposes of this study the operational char-
acteristics of community hospitals, which ac-
count for 82.1% of the Oklahoma hospital
population will be examined. (Table 3)5

Within the population of 119 community
hospitals in Oklahoma the average number of
employees per bed is 2.2. (Table 4)6 Hospitals
with a bed size from 25 to 49 beds have the
lowest number of employees per bed, namely
1.59, while the one Oklahoma community hos-
pital with bed size in the 400-499 range has an
employee per bed ratio of 2.81. Interestingly,
the larger hospitals with average bed sizes
above 200 beds, have a ratio of employees per

TABLE 4

Operational Characteristics of
Oklahoma Community Hospitals

Overall

Employees Per Diem Labor

Classification

Hospitals

Per Bed

Cost

Intensity

6 - 24 beds

1.74

$ 78.47

.545

25 - 49 beds

1.59

66.74

.525

50 - 99 beds

1.80

75.89

.527

100-199 beds

2.31

86.19

.531

200-299 beds

2.21

83.95

.540

300-399 beds

2.56

78.85

.543

400-499 beds

2.81

117.75

.547

500 & over

2.68

106.87

.527

Total

119

2.201

$ 87.34

.531

^Weighted Average

bed which varies from a low of 2.21 to a high of
2.81.

Equally interesting, while these larger hos-
pitals spend in the area of 54% of each dollar
for labor, their overall per diem cost of hos-
pitalization ranges from $78.85 to $117.75 per
equivalent inpatient day.7 The overall per
diem cost of hospitalization for all Oklahoma
community hospitals ranges from a low of
$66.74 per equivalent inpatient day to $117.75.
Part of the variation in the per diem cost of
hospitalization can be explained by the age and
size of investment in plant and capital assets.
This fact notwithstanding, the general level of
the cost of hospitalization might be ascribed in
large measure to technological advancements,
seen for example in the greater cost of diag-
nostic and treatment equipment, greater de-
mand for and specialization within skilled
labor, accompanied by such things as union-
ization and even occupational wage differ-
entials created by rising minimum wage
rates.8

WHAT HAS BEEN DONE

As a consequence of the high cost of medical
care today, we see greater government in-
volvement in the health industry, increased in-
terest in developing alternative methods of
health care delivery, and concentrated efforts
on the part of hospital administrators to con-
trol costs.9

In some quarters medical care is not viewed
as an economic issue but rather as a social
right. "As a consequence . . . the traditional
contract between the medical profession and
Society is being renegotiated with prepayment
providing the leverage to new terms that are
much closer to the public’s emerging health
care aspirations than to the profession’s cus-
tomary views.’’10 In consonance with this point
of view government backed programs such as
Medicare were implemented in mid 1966, and

James E. Perry received his BS degree from
Boston College in 1966; his MBA from Bahson
Institute in 1968 and is a PhD candidate at the
University of Oklahoma. He has served as a
consultant o several business establishments in
the Oklahoma City area. Presently he holds the
position of Assistant Professor of Finance at
Oklahoma City University.

Journal / November 1975 / Volume 68

425

Hospitalization / PERRY

today significant efforts aimed at developing
and implementing a national health insurance
program are being made.

Within the health industry tremendous ad-
vances have been made with respect to service
sharing and the development of management
systems for the purposes of cutting and/or con-
trolling costs. For the most part, management
systems programs center on the establishment
of institutional goals, financial plans and
budgets, manpower budgets, and evaluation
programs for the same, all constructed with an
eye toward rendering quality care at reason-
able cost.11 Service-sharing has been imple-
mented both in terms of treatment equipment
and the support functions, such as credit and
collections, printing and laundry.12

Other vehicles for cost containment which
have received consideration concern a shift of
emphasis from academically-trained personnel
to acquired skill personnel for health industry
support positions and the development of am-
bulatory surgery.13

Most notably, the military forces have been
cited as a potential major supplier of persons
with acquired skills.14 Such an increased sup-
ply of labor in middle level support positions
would have a dampening effect on labor cost
within the industry. So too, the development of
ambulatory surgery, which although innova-
tive, has the potential of contributing to cost
control through decreased hospital utilization.

In summary, the health care delivery system
in the United States is very costly and has
grown in magnitude for many years. To the
extent that the health system continues to
grow and the cost of medical services continues
to rise, pressures from within and outside the
industry have also increased for cost control
and institutional efficiency. These pressures

have taken form in a greater emphasis on the
development of management planning and
evaluation systems, but have also been accom-
panied by greater governmental involve-
ment. □

References

1. American Hospital Association, "The Nation’s Hospitals: A Statistical
Profile," Hospital Statistics 1974 Edition (Chicago, Illinois: American Hospital
Association, 1974), p. 6.

2. American Hospital Association, "The Nation’s Hospitals: A Statistical
Profile," Hospital Statistics 1974 Edition (Chicago, Illinois: American Hospital
Association, 1974), p. 6.

3. American Hospital Association, "The Nation’s Hospitals: A Statistical
Profile," Hospital Statistics 1974 Edition (Chicago, Illinois: American Hospital
Association, 1974), p. 128.

4. American Hospital Association, "The Nation's Hospitals: A Statistical
Profile,” Hospital Statistics 1974 Edition (Chicago, Illinois: American Hospital
Association, 1974), p. 128.

5. Community Hospitals are nonfederal, short term general: maternity; eye,
ear, nose, and throat; children's; orthopedic; chronic; and other special hospi-
tals other than psychiatric and tuberculosis.

6. Calculations include the number of persons on payroll at close of reporting
period for American Hospital Association annual survey purposes (Sept. 30,
1973): includes full-time equivalents of part time personnel but excludes
trainees, private nurses, and volunteers. Full time equivalents were calculated
on the basis that two part-time persons equal one full-time person.

7. Equivalent Inpatient Day is an aggregate figure reflecting the number of
days of inpatient care plus an estimate of the volume of outpatient services,
expressed in units equivalent to an inpatient day in level of effort. Derived by
multiplying number of outpatient visits by the ratio of outpatient revenue per
outpatient visit to inpatient revenue per inpatient day, producing the number
of adjusted patient days attributable to outpatient services. The number of
inpatient days plus the number of adjusted patient days equals the inpatient
day equivalent.

8. Roger M. Battistella, "The Right To Adequate Health Care,” Hospital
Progress (December, 1974), p. 36. William C. Johnson, "Hospital Labor Costs
and Manpower Utilization,” Hospital Progress (March, 1973), pp. 64-66. The
reader is also referred to: Albert W. Snoke and Parnie S. Snoke, "A Blueprint
For Chang e," Hospitals, Journal of the American Hospital Association, Vol. 48
(July 1, 1974), pp. 61-64., wherein the author discusses the implication of a
lack of a rational state, federal, or voluntary health policy or strategy.

9. Peter Rogatz, "Excessive Hospitalization Can Be Cut Back," Hospitals,
Journal of the American Hospital Associaton, Vol. 48 (August 1, 1974), pp.
51-56.

10. William McKillop, "Is High-Quality Care Assessable,” Hospitals, Jour-
nal of the American Hospital Association, Vol. 49 (January 16, 1975), p. 36. See
also: Battistella, Op. Cit., p. 36 ff.

11. Arvind Salvekar, "Management Engineering Reduces Cost/Improves
Car e, " Hospital Progress (January, 1975), pp. 28-30. Addison C. Bennett, "Re-
ducing Hospital Costs," Hospital Topics (March, 1973), pp. 27-32. Robert N.
Davis, "Productivity Improvement Can Cut Costs,” Hospitals, Journal of the
American Hospital Associaton, Vol. 49 (February 16, 1975), pp. 49-52.

12. Gerald W. Schilling, "Cost Containment Through Sharing," Hospitals,
Journal of the American Hospital Association, Vol. 49 (January 16, 1975), pp.
48-51.

13. Rogatz, Op. Cit., p. 54. Johnson, Op. Cit., p. 68.

14 William C. Johnson, "Hospital Labor Costs and Manpower Utilization,”
Hospital Progress (March, 1973), p. 68.

Assistant Professor of Finance, School of Business,
Oklahoma City University, Oklahoma City,
Oklahoma.

Remember these dates —

May 6th, 7th, 8th, 9th, 1976
OKLAHOMA MEDICAL SUMMIT ’76

Lincoln Plaza Forum
Oklahoma City, Oklahoma

426

Oklahoma State Medical Association

News From
The Oklahoma State
Department of
Health

A workable communicable disease surveil-
lance system is now available to the physicians
of Oklahoma. The role of the local health
department is expanded under this new sys-
tem. The objective is to simplify the reporting
of those diseases that affect the general health
of all the people. All physicians and public
health officials obviously realize the need to
respond quickly and appropriately to com-
municable diseases.

The local health department is responsible
for distributing and collecting the cards and
forwarding the information to the Epidemiol-
ogy Division of the State Health Department.
The cards are to remain on file for a six-month
period in the local health department. The
cards require no postage and are self addressed
to simplify handling. Physicians are reminded
that they are required by law to report the
communicable diseases listed on the card.
Failure or refusal to report these diseases shall
constitute a misdemeanor. □

Oklahoma State Department of Health
Weekly Communicable Disease Report

The following diseases should be reported immediately by telephone to your local county
health department.*

Botulism
Cholera
Diphtheria
Encephalitis
Food Poisoning
Gonorrhea
Hepatitis B
Malaria

Meningococcal Infections

Pertussis

Plague

Poliomyelitis

Rabies (Man or Animal)

Relapsing Fever

Rocky Mountain Spotted Fever
Rubella

Rubella, Congenital Syndrome
Rubeola

Smallpox
Syphilis
Tetanus
Trichinosis
Tuberculosis
Typhoid Fever
Typhus Fever
Yellow Fever
Unusual Syndromes
and Outbreaks

Report by Number of Cases Only:

Actinomycosis

Amebiasis

Anthrax

Aseptic Meningitis

Blastomycosis

Brucellosis

Chickenpox(Varicella)

Coccidioidomycosis

Hepatitis A

Hepatitis (Unspecified)
Histoplasmosis
Influenza Syndrome
Leprosy
Leptospirosis

Lymphogranuloma Venereum
Mumps

Psittacosis

Rheumatic

Fever(Acute)

Salmonellosis

Shigellosis

Toxoplasmosis

Tularemia

Report should be mailed each Friday unless Friday is an official holiday, in which case the
report should be mailed on the last working day of the week.

*Should you not be able to reach your county health department, (i.e., nights and week-ends)
call the State Epidemiologist in Oklahoma City, (405) 271-4060. (Toll Free)

Your reporting is critically important to the disease control efforts of your health department.
The few minutes per week required in completing this form are appreciated. Thank You!

□ Check here if you need more cards.

Physician's Name

The Oklahoma Public Health Code. 1963,
Article 5. paragraphs 1-502 and 1 503 and
the State Board of Health regulations adopted
December 8, 1968. require that practicing
physicians, clinical laboratories, hospitals,
penal and charitable institutions report these
communicable diseases as listed. Failure or
refusal to report diseases as required by the
Board shall constitute a misdemeanor.

Date Report Submitted

ODH Form No. 295/Rev. 1975

COMMUNICABLE DISEASES IN OKLAHOMA FOR SEPTEMBER, 1975

DISEASE

September

1975

September

1974

August

1975

Total To Date
1975 1974

Amebiasis

Brucellosis

—

Chickenpox

960

816

Encephalitis, Infectious

Gonorrhea (Use Form ODH-228)

1251

1020

1324

9826

8411

Hepatitis, A, B, Unspecified

627

771

Leptospirosis

—

Malaria

—

Meningococcal Infections

—

Meningitis, Aseptic

Mumps

193

372

Rabies in Animals

126

Rheumatic Fever

—

Rocky Mountain Spotted Fever

Rubella

—

Rubella, Congenital Syndrome

—

Rubeola

—

132

Salmonellosis

187

203

Shigellosis
Syphilis, Infectious

269

138

(Use Form ODH-228)

109

Tetanus

—

Tuberculosis, New Active

238

227

Tularemia

Typhoid Fever

—

Whooping Cough

For Consultation Call: (405) 271-4060

Journal / November 1975 / Volume 68

427

demands

patients may need

Convenient once-a-day dosage
Reasonable cost'"

emia’,’ in euthyroid, non-cardiac patient*

'//: 1 I T FLINT LABORATORIES

DIVISION OF TRAVENOL LABORATORIES. INC.

Deerfield, Illinois 60015

See reverse side for full prescribing information

Choloxin (sodium dextrothyroxine)

The Lipid-Lowering Agent with
Once-A-Day Dosage

Four strengths ... 1 , 2, 4, and 6 mg. . . . are available making
the scored tablet regimen a flexible dosage system. And, for
most patients, CHOLOXIN tablets offer once-a-day dosage.

AN IMPORTANT NOTE:

It has not been established whether the drug-
induced lowering of serum cholesterol or lipid
levels has a detrimental, beneficial, or no effect
on the morbidity or mortality due to atheroscle-
rosis or coronary heart disease. Several years will
be required before current investigations will
yield an answer to this question.

CHOLOXIN" (sodium dextrothyroxine) Single-Tablet-A-Day Dosage Schedules

See prescribing information in package insert reproduced below.

Starting

Increased

Usual

Maximal

Dosage

Monthly by

Maintenance

Recommended

Adult Hypercholesterolemic

1 .0-2.0 mg.

4. 0-8.0 mg.

Pediatric Hypercholesterolemic

0.05 mg. /kg. body weight

0.05 mg. /kg.

0.1 mg. /kg. body weight

4.0 mg.

Hypothyroid Cardiac

0.5-1 .0 mg.

1 .0 mg.

4.0 mg.

Choloxin

(sodium dextrothyroxine)

Description

CHOLOXIN (sodium dextrothyroxine) is
the sodium salt of the dextrorotatory
isomer of thyroxine. It is chemically
described as D-3,5,3',5'-tetraiodothyro-
nine sodium salt.

Actions

The predominant effect of CHOLOXIN
(sodium dextrothyroxine) is the reduc-
tion of serum cholesterol levels in
hyperlipidemic patients. Beta lipopro-
tein and triglyceride fractions may
also be reduced from previously ele-
vated levels.

Most of the available evidence indi-
cates that CHOLOXIN stimulates the
liver to increase catabolism and excre-
tion of cholesterol and its degradation
products via the biliary route into the
feces. Cholesterol synthesis is not in-
hibited and abnormal metabolic end-
products do not accumulate in the
blood.

Indications

This is not an innocuous drug. Strict
attention should be paid to the indica-
tions and contraindications.

CHOLOXIN (sodium dextrothyroxine) is
an antilipidemic agent used as an ad-
junct to diet and other measures for
the reduction of elevated serum cho-
lesterol (low density lipoproteins) in
euthyroid patients with no known evi-
dence of organic heart disease.

The drug is also indicated in the treat-
ment of hypothyroidism in patients
with cardiac disease who cannot toler-
ate other types of thyroid medication.

I Before prescribing, note the following:
Results from a randomized clinical
study have indicated a possible adverse
effect when CHOLOXIN is administered
to a patient receiving a digitalis prep-
aration. There may be an additive
effect. This additive effect may possi-
bly stimulate the myocardium exces-
sively in patients with significant
myocardial impairment. CHOLOXIN dos-

Iage should not exceed 4 mg per day
when the patient is receiving a digitalis
preparation concomitantly. Careful
monitoring of the total effect of both
drugs is important.

It has not been established whether
the drug-induced lowering of serum
cholesterol or lipid levels has a detri-
mental, beneficial, or no effect on the
morbidity or mortality due to athero-
sclerosis or coronary heart disease.
Several years will be required before
current investigations will yield an
answer to this question.

Contraindications

The administration of CHOLOXIN (so-
dium dextrothyroxine) to euthyroid
patients with one or more of the fol-
lowing conditions is contraindicated:

1. Known organic heart disease, in-
cluding angina pectoris; history of
myocardial infarction; cardiac ar-
rhythmia or tachycardia, either
active or in patients with demon-
strated propensity for arrhyth-
mias; rheumatic heart disease;
history of congestive heart fail-
ure; and decompensated or bor-
derline compensated cardiac
status.

2. Hypertensive states (other than
mild, labile systolic hypertension).

3. Advanced liver or kidney disease.

4. Pregnancy.

5. Nursing mothers.

6. History of iodism.

Warnings

CHOLOXIN (sodium dextrothyroxine)
may potentiate the effects of antico-
agulants on prothrombin time. Reduc-
tions of anticoagulant dosage by as
much as 30% have been required in
some patients. Consequently, the dos-
age of anticoagulants should be re-
duced by one-third upon initiation of
CHOLOXIN therapy and the dosage sub-
sequently readjusted on the basis of
prothrombin time. The prothrombin
time of patients receiving anticoagu-
lant therapy concomitantly with CHO-
LOXIN therapy should be observed as
frequently as necessary, but at least
weekly, during the first few weeks of
treatment.

In the surgical patient, it is wise to
consider withdrawal of the drug two
weeks prior to surgery if the use of
anticoagulants during surgery is con-
templated.

When CHOLOXIN is used as thyroid
replacement therapy in hypothyroid
patients with concomitant coronary
artery disease (especially those with a
history of angina pectoris or myocar-
dial infarction) or other cardiac dis-
ease, treatment should be initiated
with care. Special consideration of the
dosage schedule of CHOLOXIN is re-
quired. This drug may increase the
oxygen requirements of the myocar-
dium, especially at high dosage levels.
Treated subjects with coronary artery
disease must be seen at frequent in-
tervals. If aggravation of angina or
increased myocardial ischemia, cardiac
failure, or clinically significant ar-
rhythmia develops during the treatment
of hypothyroid patients, the dosage
should be reduced or the drug discon-
tinued.

Special consideration must be given to
the dosage of other thyroid medications
used concomitantly with CHOLOXIN. As
with all thyroactive drugs, hypothyroid
patients are more sensitive to a given
dose of CHOLOXIN than euthyroid pa-
tients.

Epinephrine injection in patients with
coronary artery disease may precipi-
tate an episode of coronary insuffi-
ciency. This condition may be enhanced
in patients receiving thyroid analogues.
These phenomena should be kept in
mind when catecholamine injections
are required in sodium dextrothyroxine-
treated patients with coronary artery
disease.

Since the possibility of precipitating
cardiac arrhythmias during surgery
may be greater in patients treated
with thyroid hormones, it may be
wise to discontinue CHOLOXIN in
euthyroid patients at least two weeks
prior to an elective operation. During
emergency surgery in euthyroid pa-
tients, and in surgery in hypothyroid
patients in whom it may be advisable
to withdraw therapy, the patients
should be carefully observed.

There are reports that sodium dextro-
thyroxine in diabetic patients is capa-
ble of increasing blood sugar levels
with a resultant increase in require-
ments of insulin or oral hypoglycemic
agents. Special attention should be
paid to parameters necessary for good
control of the diabetic state in dextro-
thyroxine-treated subjects and to
dosage requirements of insulin or other

antidiabetic drugs. If sodium dextro-
thyroxine is later withdrawn from
patients who had required an increase
of insulin (or oral hypoglycemic agents)
dosage during its administration, the
dosage of antidiabetic drugs should be
reduced and adjusted to maintain good
control of the diabetic state.

When either or both impaired liver or
kidney function are present, the advan-
tages of CHOLOXIN therapy must be
weighed against the possibility of del-
eterious results.

Usage in Women of Childbearing Age

Women of childbearing age with famil-
ial hypercholesterolemia or hyperlipe-
mia should not be deprived of the use
of this drug; it can be given to those
patients exercising strict birth control
procedures. Since pregnancy may occur
despite the use of birth control pro-
cedures, administration of CHOLOXIN
(sodium dextrothyroxine) to women of
this age group should be undertaken
only after weighing the possible risk
to the fetus against the possible bene-
fits to the mother. Teratogenic studies
in two animal species have resulted in
no abnormalities in the offspring.
Precautions

It is expected that patients on dextro-
thyroxine therapy will show greatly
increased serum protein-bound-iodine
levels. These increased serum P B I
values are evidence of absorption and
transport of the drug, and should NOT
be interpreted as evidence of hyper-
metabolism; similarly, they may not be
used for titrating the effective dose of
CHOLOXIN (sodium dextrothyroxine).
PBI values in the range of 10 to 25
mcg% in treated patients are common.
If signs or symptoms of iodism develop
during CHOLOXIN therapy, the drug
should be discontinued.

A few children with familial hypercho-
lesterolemia have been treated with
CHOLOXIN for periods of one year or
longer with no adverse effects on
growth. However, it is recommended
that the drug be continued in patients
in this age group only if a significant
serum cholesterol-lowering effect is
observed.

Adverse Reactions

The side effects attributed to dextro-
thyroxine therapy are, for the most
part, due to increased metabolism, and
may be minimized by following the
recommended dosage schedule. Ad-
verse effects are least commonly seen
in euthyroid patients with no signs or
symptoms of organic heart disease; the
incidence of adverse effects is in-
creased in hypothyroid patients, and is
highest in those patients with organic
heart disease superimposed on the
hypothyroid state.

In the absence of known organic heart
disease, some cardiac changes may be
precipitated during sodium dextrothy-
roxine therapy. In addition to angina
pectoris, arrhythmia consisting of
extrasystoles, ectopic beats, or supra-
ventricular tachycardia, ECG evidence
of ischemic myocardial changes and
increase in heart size have been ob-
served. Myocardial infarctions, both
fatal and non-fatal, have occurred, but
these are not unexpected in untreated
patients in the age groups studied. It
is not known whether any of these in-
farcts were drug related.

Changes in clinical status that may be
related to the metabolic action of the
drug include the development of in-
somnia, nervousness, palpitations,

tremors, loss of weight, lid lag, sweat-
ing, flushing, hyperthermia, hair loss,
diuresis, and menstrual irregularities.
Gastrointestinal complaints during
therapy have included dyspepsia, nau-
sea and vomiting, constipation, diar-
rhea, and decrease in appetite.

Other side effects reported to be
associated with CHOLOXIN (sodium
dextrothyroxine) therapy include the
development of headache, changes in
libido (increase or decrease), hoarse-
ness, tinnitus, dizziness, peripheral
edema, malaise, tiredness, visual dis-
turbances, psychic changes, paresthe-
sia, muscle pain, and various bizarre
subjective complaints. Skin rashes, in-
cluding a few which appeared to be
due to iodism, and itching have been
attributed to dextrothyroxine by some
investigators. Gallstones have been
discovered in occasional dextrothyrox-
ine-treated patients and cholestatic
jaundice has occurred in one patient,
although its relationship to CHOLOXIN
therapy was not established.

In several instances, the previously
existing conditions of the patient ap-
peared to continue or progress during
the administration of CHOLOXIN; a
worsening of peripheral vascular dis-
ease, sensorium, exophthalmos, and
retinopathy have been reported.
CHOLOXIN potentiates the effects of
anticoagulants, such as warfarin or
Dicumarol, on prothrombin time, thus
indicating a decrease in the dosage
requirements of the anticoagulants. On
the other hand, dosage requirements
of antidiabetic drugs have been re-
ported to be increased during dextro-
thyroxine therapy (see WARNINGS
section).

Dosage and Administration
Lor adult euthyroid hypercholesterol-
emic patients, the recommended main-
tenance dose of CHOLOXIN (sodium
dextrothyroxine) is 4 to 8 mg per day.
The initial daily dose should be 1 to 2
mg to be increased in 1 to 2 mg incre-
ments at intervals of not less than one
month to a maximum level of 4 to 8
mg daily, if that dosage level is indi-
cated to effect the desired lowering of
serum cholesterol.

When used as partial or complete sub-
stitution therapy for levothyroxine in
hypothyroid patients with cardiac dis-
ease who cannot tolerate other types
of thyroid medication, the initial daily
dose should be 1 mg to be increased
in 1 mg increments at intervals of not
less than one month to a maximum
level of 4 to 8 mg daily, preferably the
lower dosage. The maximum in patients
receiving digitalis therapy is 4 mg.

For pediatric hypercholesterolemic pa-
tients, the recommended maintenance
dose of CHOLOXIN is approximately 0.1
mg per kilogram. The initial daily dos-
age should be approximately 0.05 mg
per kilogram to be increased in up to
0.05 mg per kilogram increments at
monthly intervals. The recommended
maximal dose is 4 mg daily, if that
dosage is indicated to effect the de-
sired lowering of serum cholesterol.

If new signs or symptoms of cardiac
disease develop during the treatment
period, the drug should be withdrawn.
How Supplied

CHOLOXIN (sodium dextrothyroxine) is
supplied in prescription packages of
scored 1, 2, 4, and 6 mg tablets.

FLINT LABORATORIES

Division of travenol laboratories, inc
Deerfield, Illinois 60015

Trustees Continue Search
For Alternative UR Plan

The association’s Board of Trustees decided
on October 26th to authorize further nego-
tiations with the Assistant Secretary of the
Department of Health, Education and Welfare
in an effort to gain approval of an OSMA-
developed alternative to onerous hospital utili-
zation review regulations for Medicare and
Medicaid patients.

OSMA has been preimminent nationwide in
its objections to cost-control concepts being ad-
vocated by the federal government. Federal of-
ficials are desperately trying to curb burdgeon-
ing expenses of the $24 billion-a-year health
care plans.

At the 1975 annual meeting of the
association’s House of Delegates last April, a
resolution was adopted which called for non-
compliance with new federal utilization review
regulations being imposed at that time.

These regulations, later to be the victim of a
partially-successful AMA lawsuit, called for
the certification of the medical necessity of
each Medicare and Medicaid admission within
24 hours after the patient’s entry into the hos-
pital. This feature, in addition to a case-by-case
review of all "long-stay” admissions, was seen
by most Oklahoma physicians as being pro-
fessionally disruptive, administratively ineffi-
cient, economically mis-directed as a cost-
saving device, and unworkable in the many
small rural hospitals of the state. Moreover,
the 24-hour certification rule, and the resul-
tant loss of Medicare-Medicaid benefits, could
have deprived many patients of necessary med-
ical services.

The House of Delegates authorized a vol-
untary assessment of the association member-
ship to raise funds necessary to carry out a pol-
icy of non-participation, and nearly $60,000
was collected. However, the AMA asked that
the Oklahoma campaign be tabled until its
lawsuit against DHEW was resolved, and at
this point the OSMA Council on Public Policy
and Officers of the OSMA met with the state’s
Congressional Delegation and federal officials

430

in Washington for the purpose of finding other
means to settle the dispute.

At the meeting, the Assistant Secretary of
DHEW, Theodore Cooper, MD, invited the
OSMA to develop an alternative "superior
plan” for possible application to Oklahoma in
lieu of the federal regulations.

Association staff and the Council on Public
Policy developed such an alternative by late
June, and in July negotiations began to put the
OSMA plan in place as a "demonstration pro-
ject” which, if successful, could alter federal
policy.

Meanwhile, as a result of the AMA lawsuit,
DHEW Secretary Matthews withdrew the con-
troversial regulations and said new cost-
control rules would be drafted for imple-
mentation in the Fall.

osma"cost-effectiveness program”

The association concept differs from the pre-
vailing federal attitude in that primary em-
phasis would be placed on retrospective audit
of overall hospital medical staff performance
rather than by concentrating on the harrass-
ment of individual physicians through the fed-
eral concept of case-by-case review.

Under the OSMA plan, stringent review
rules would only be focused on those hospital
medical staffs and individual doctors who are
determined by retrospective audit to be signif-
icantly deviant from acceptable professional
standards as established by peer norms. Con-
versely, medical staffs with acceptable perfor-
mance records of admission rates and lengths-
of-stay would be "waivered” from most concur-
rent case-by-case review requirements as en-
visioned by federal officials. It is believed by
those who understand the OSMA concept that
its technique of selective "focused review,”
based on deviations identified by retrospective
audit, will attain the same cost control objec-
tive desired by the government with greater
professional acceptance and at considerably
less expense.

The OSMA plan, if approved as a national
demonstration project, would be operated by a
division of the Oklahoma Foundation for Peer
Review, an organization created by the OSMA
to study the implementation of the federal
"Professional Standards Review Organization”
law. Another division of the foundation has al-
ready received a one-year $114,000 federal
contract to plan for PSRO implementation and,
conceivably, the utilization review concept of

Oklahoma State Medical Association

the OSMA-designed demonstration project
could be adapted later on as the PSRO pro-
totype for the state. Moreover, as mentioned
above, a successful demonstration of the
OSMA concept could possibly alter national
PSRO policy.

APPROVAL BESET BY DELAYS

Although the association plan has been sup-
ported from the outset by Assistant Secretary
Cooper, by the Director of the Bureau of Health
Insurance (Medicare), and by the top federal
Medicaid official, final Washington action has
been delayed by legal entanglements, by a con-
fused federal bureaucracy, and by the out-of-
court settlement of the AMA lawsuit which
temporarily called back current utilization re-
view regulations for a massive re-write.

Washington officials have been in constant
telephone contact with OSMA staff and, on one
occasion, eight federal representatives spent
two days in the OSMA offices discussing the
association’s proposal.

At present, it is expected that legal barriers
to the approval of the demonstration project
will be resolved in early November when

DHEW Secretary David Matthews approves an
amendment to Medicare regulations drafted by
Assistant Secretary Cooper and his staff. This
amendment will then pave the way for final
approval of the plan and an expected imple-
mentation date of January 1st.

The association’s- Board of Trustees has re-
served the final authority to give the go-ahead
sign after all elements of the negotiations are
known and after comparisons are made to the
new utilization review requirements now
being drafted in Washington. There is spec-
ulation that new federal regulations may re-
quire preadmission certification of all elective
surgery — a feature which could be avoided
under the OSMA plan — and it is rather cer-
tain at this point that new regs will at best be
considerably more stringent and professionally
aggravating than the OSMA proposal.

OSMA’s Board of Trustees may request a
special House of Delegates meeting in De-
cember if warranted by the circumstances and
if there is any question at that time that Board
actions may have violated or compromised the
April resolution of the Delegates regarding
non-compliance with the now withdrawn fed-
eral regulations. □

HEALTH CARE MANAGEMENT

MASSES OF PAPERWORK AND SLOW RECEIVABLES
. . these two enemies are overwhelming todays Medical
Office! How to deal with these two is the “number one
business problem’’ for many doctors.

HCM's system is simple, easy to learn, requires no
special equipment, is flexible, and can follow along the
lines of your present business office procedures.

For further information, contact:
Gene Highfill

Academy Computing Corporation
3535 NW 58th — Suite 102
Oklahoma City, Oklahoma 73112
405/947-7746

Journal / November 1975 / Volume 68

431

news

Malpractice Insurance
Problems Studied

While malpractice insurance has become a
significant problem to physicians in many
states, Oklahoma doctors fare better than
most, and so do their patients. So says a recent
report by David K. McCurdy, assistant Okla-
homa attorney general.

According to the report, Oklahoma remains
in a relatively favorable position with respect
to insurance rates and availability. 'This re-
sults,” it says, "in more reasonable and effi-
cient medical care for the patient.”

In his report to the Legislative Council’s in-
surance committee, McCurdy says the mal-
practice insurance program offered by the
Oklahoma State Medical Association "appears
to have some of the lowest premium rates in
the United States.” Virtually every practicing
physician in Oklahoma, it says, carries mal-
practice insurance through the OSMA pro-
gram.

While increased exposure to the public,
greater use of potent drugs, a change in medi-
cal technology, greater interest and a more
litigation-minded public have all contributed
to the rise in malpractice suits, says the report,
several other factors have worked in
Oklahoma’s favor. First of all, Oklahoma is not
urbanized and therefore, the state is temporar-
ily insulated from many of the urban ills. Sec-
ondly, Oklahoma physicians appear to have a
strong and effective state medical society
which provides many benefits, including a
group insurance program.

Due to the working relationship between the
physician, the OSMA, and the insurer, it says,
"Oklahoma is currently not faced with a prob-
lem of excessive rates or unavailability.”

The assistant attorney general goes on to
warn, however, that Oklahoma’s enviable posi-
tion may not be as permanent as the physician
and his patients might like. In light of an oppo-
site national trend, he says, "Oklahoma’s posi-
tion is indeed precarious.” In order to forestall
intensification and expansion of the problem,
he predicts, preventive legislation will be
necessary.

To date, the OSMA has endorsed five bills
due to be reconsidered in the next session of the
Oklahoma legislature. A list of OSMA en-
dorsed bills and a brief description of their in-
tent is shown below.

432

S.B. 450 . . . This bill would establish a sta-
tute of limitations for cases involving alleged
malpractice. It would require malpractice suits
to be filed within one year from the date of the
injury, except in special cases involving dis-
covery. In those cases, a maximum period of
four years would be allowed.

S.B. 428 . . . This bill is designed to discour-
age the filing of non-meritorious lawsuits. It
would allow the physician to file a "counter-
claim.” If the physician was found NOT neg-
ligent, the alleged injured party would have
lost his suit to the physician.

S.B. 429 . . . This bill would provide that no
guaranty or warranty of medical care would be
valid unless stated in writing.

S.B. 451 . . . This bill would make informa-
tion available to the jury concerning collateral
sources of recovery available to the plaintiff.

S.B. 452 . . . This bill would serve to clarify
the application of the res ipsa loquitur doc-
trine.

Further efforts to attack the problems in-
volved with malpractice insurance are being
made by the Professional Liability Study
Commission appointed by Arnold G. Nelson,
MD, OSMA President.

The commission recommended the OSMA
study three proposals as a means of reducing
the frequency of malpractice claims in Okla-
homa. The proposals recommended by the
commission at its September 7th meeting are:

1. The establishment of a required course in
professional liability for junior and senior stu-
dents at the University of Oklahoma College of
Medicine.

2. The establishment of a "Legal Indoctrina-
tion Course” for all state physicians. The
course would be offered about two times a year,
and efforts would be made to reduce the insur-
ance premiums for participating physicians by
about ten per cent.

3. That Continuing Medical Education be
considered as a requirement for either OSMA
membership or as a re-licensure requirement.

Executive Director Don Blair indicates the
OSMA and its committees will continue to look
into ways of solving the malpractice insurance
problem.

Editor’s Note: The full report by the Assistant
Attorney General will be featured in a future
issue of The Journal. d

Oklahoma State Medical Association

BEVERLY HILLS HOSPITAL
BEVERLY HILLS CLINIC

PSYCHIATRY
INPATIENT - OUTPATIENT
DEPARTMENT OF ADOLESCENT PSYCHIATRY

PSYCHIATRY

Jackson H. Speegle, MD
John T. Holbrook, MD

Fred H. Jordan, MD
Joseph H. Lindsay, MD

PSYCHOLOGY

George R. Mount, PhD Tom I. Payton, MS

Donald L. Whaley, PhD Patrick R. Barnes, MS

EDUCATION DIRECTOR

William E. Nix, PhD

DIRECTOR OF NURSES

Nita Ivey, RN

O.T. AND R.T. ACTING DIRECTOR

Jeanette Boothe

COURTESY STAFF

1353 North Westmoreland Avenue, DALLAS, TEXAS 75211 214 331-8331

Journal / November 1975 / Volume 68

433

news

Program Completed for AMA
Tulsa Regional Meeting

Tulsa will be the site of the AMA Regional
Meeting on January 17th-18th, 1976. These
Category 1 CME Courses will be held at the
Tulsa Hilton Hotel. Co-sponsoring organiza-
tions along with the AMA include the Univer-
sity of Oklahoma Tulsa Medical College, the
Tulsa Medical Education Foundation, the
Tulsa County Medical Society and the Okla-
homa State Medical Association.

Medical students and house staff physicians
will be able to attend the courses free of charge.

The course schedule is as follows:

Saturday, January 17th, 1976

1. THE CHILD IN THE EMERGENCY
ROOM — 8:00 a. m. -3:00 p.m. — Major case
problems will be presented including man-
agement of multiple injuries, coma, seizures,
poisoning, cardiorespiratory collapse, bites and
stings and anaphylaxis. Faculty: Daniel C.
Plunket, MD, Tulsa, Course Director; Delmer
J. Pascoe, MD, San Francisco, California;
Robert W. Block, MD, Tulsa; Charles L.
Cooper, MD, Tulsa; Harold E. Goldman, MD,
Tulsa; and Ralph W. Richter, MD, Tulsa.

2. FINANCIAL MANAGEMENT (AMA
Course) — 8:00 a. m. -3:00 p.m.

3. BASIC LIFE SUPPORT COURSE IN
CARDIOPULMONARY RESUSCITATION
(Oklahoma Heart Association Course) — 7:30
a. m. -Noon.

4A. RECENT ADVANCES IN CARDIAC
MANAGEMENT — 1:00-3:00 p.m. — Current
management of the acutely ill patient with
coronary artery disease, primarily acute myo-
cardial infarction, will be stressed. In addition,
one presentation will be devoted to the ways in
which emergency medical care can be extended
to the patient in the pre-hospital phase of acute
myocardial infarction and to a system by which
the smaller community hospital can provide
monitoring and update its care of the patient
with myocardial infarction. Faculty: Loyal L.
Conrad, MD, Tulsa, Course Director; Gerald L.
Honick, MD, Oklahoma City; Paul C. Houk,
MD, Oklahoma City; John M. Kalbfleisch, MD,

Tulsa; Robert E. Lynch, MD, Tulsa; Jose R.
Medina, MD, Tulsa; R. Wayne Neal, MD,
Tulsa; Billy P. Loughridge, MD, Tulsa; Charles
W. Robinson, Jr., MD, Oklahoma City; Richard
C. Slagle, MD, Tulsa; and Robert P. Zoller,
MD, Tulsa.

Sunday, January 18th, 1976

4A. continued — RECENT ADVANCES IN
CARDIAC MANAGEMENT — 8:00 a.m.-3:00
p.m.

5. DERMATOLOGY FOR NON-
DERMATOLOGISTS — 8:00 a. m. -3:00 p.m. —
Cutaneous conditions commonly encountered
in medical practice will be presented. Atopic
dermatitis, cutaneous lesions in systemic dis-
ease, common cutaneous infections and benign
and malignant cutaneous lesions will be re-
viewed. Current dermatologic therapy as well
as review of diagnostic clues will be stressed.
Faculty: Dwane B. Minor, MD, Tulsa, Course
Director; Mark Allen Everett, MD, Oklahoma
City; and Larry Millikan, MD, Columbia, Mis-
souri.

6. MANAGEMENT OF THE CRITICALLY
INJURED PATIENT — 8:00 a.m.-3:00 p.m. —
With the increasing incidence of multiple-
injured patients, an increasing burden of re-
sponsibility is being placed on the physician
who works in the emergency department on a
full or part-time basis. Head, neck and spinal
injuries; thoracic, abdominal and genitourinary
injuries will be reviewed. Management of
shock, airway and cardiopulmonary compli-
cations will also be stressed. Faculty: C. T.
Thompson, MD, FACS, Course Director; Clar-
ence I. Britt, MD, Tulsa; J. C. Devine, MD,
Tulsa; Gerald E. Gustafson, MD, Tulsa; Robert
L. Imler, Jr., MD, Tulsa; John M. Kalbfleisch,
MD, Tulsa; Edward O. Nonweiler, MD, Tulsa;
John Phillips, MD, Tulsa.

7. ACID-BASE, FLUID AND ELECTRO-

LYTE BALANCE — 8:00 a.m.-3:00 p.m. —
The course objective is to provide a rationale
for treatment of electrolyte, acid-base and
water balance based on current understanding
of normal physiology and pharmacology. Fac-
ulty: T. Richard Medlock, MD, Tulsa, Course
Director; Jerome Kassirer, MD, Boston, Mas-
sachusetts; Solomon Papper, MD, Oklahoma
City, and Robert W. Schrier, MD, Denver,
Colorado. □

434 Oklahoma State Medical Association

FOR O.S.M.A. MEMBERS

GROUP LIFE INSURANCE

Including Disability Waiver of Premium, Accidental Death and
Dismemberment, and Common Carrier Coverage.

Moderate-cost protection up to $250,000 (depending on age)

Underwritten by Massachusetts Mutual Life Insurance
Springfield, Mass.

For additional details and application form, please contact

Jim Thaxton

Administrator

720 N. W. 50th Telephone 405 848-7661

P.O. Box 18593 Oklahoma City, Oklahoma 73118

THE WILSON AGENCY

MASSACHUSETTS MUTUAL Life Insurance Company, Springfield, Massachusetts

DOCTOR, WHAT WILL YOU EARN?

It depends, of course, on your age and annual earnings, but the amount can quite reasonably
exceed $400,000.

Is this logical? Not when you can participate in the . . .

O.S.M.A. GROUP DISABILITY INCOME PROGRAM

Now Available to members of the OKLAHOMA STATE MEDICAL ASSOCIATION
. . . gives you individual coverage at low group rates.

. . . offers flexible waiting periods at your option.

. . . guarantees you an income when you are disabled from an accident or sickness.

. . . offers optional Indemnity from $200.00 to $2,500.00 per month.

. . . pays for lifetime on accident and up to age 65 on sickness.

For Additional information, call or write

Jim Thaxton, Bill Howard or Rodman A. Frates
C. L. FRATES & COMPANY, INC.

720 N.W. 50th P.O. Box 18695
OKLAHOMA CITY, OKLAHOMA 73118
Telephone 405 848-7661

Journal / November 1975 / Volume 68

435

news

Proposed Legislation Would Overhaul
Workmen’s Compensation System

A bill due to be introduced before the next
session of the Oklahoma Legislature calls for
an effective overhaul of Oklahoma’s system of
workmen’s compensation. It was drafted by a
special subcommittee of the Governor’s Com-
mission on Workmen’s Compensation.

The proposed legislation is designed to aid
both the physician and the State Industrial
Court judge in compensation cases, allowing
both to make judgments only in areas where
they are trained. No longer would a physician
be required to make subjective evaluations as
to the per cent of disability. Likewise, impar-
tial, third party medical expertise would be
provided in cases where the medical opinions
offered by the defendant and plaintiff differed
concerning the cause of the disease or injury or
differed greatly as to the percentage of im-
pairment. Currently, such a difference must be
negotiated by the industrial court judge, and
he has the responsibility for making the final
decision.

Under the planned system, medical evidence
introduced by the employee and the employer
would include an evaluation of the percentage
of permanent impairment, but not the percent-
age of permanent disability. This would sub-
stantially lessen the burden on the physician,
allowing him to confine his testimony to physi-
cal functioning, and it would relieve him of the
responsibility of relating impairment to a
specific job. For years, physicians have
reasoned they are trained to make impairment
evaluations but not the more subjective
evaluations of disability. Under the bill, dis-
ability judgments would become the re-
sponsibility of the court.

In cases where the physicians for the em-
ployee and the employer could not agree on the
cause of the disease or injury, or their evalua-
tions of impairment differed by 20 per cent or
more, the bill calls for the interested parties to
choose a mutually agreeable third physician to
make the final determination of impairment. If
the two are not able to agree upon a third
physician, one or more would be chosen by the
judge from a medical panel established by the
bill.

The medical panel is a concept currently
being used by several other states. It would be
made up of 60 physicians representing each of

436

the specialty fields recognized by the American-
Medical Association and the American Osteo-
pathic Association. Forty of the physicians
would come from a list provided by the Okla-
homa State Medical Association and 20 would
come from a list provided by the Oklahoma
Osteopathic Association. Participating physi-
cians would serve two-year terms.

Any physician chosen from the panel to ap-
pear before the court would have full access to
all medical records, and he would be able to
make any additional tests he felt were neces-
sary. His evaluation of impairment would be
conclusive and binding on the court, and the
physician would be immune from all liability
resulting from his appearance as an expert
medical witness.

At this point, it is not definite who will in-
troduce the legislation, but the OSMA plans to
support the measure in principle. Not only
would it get the physician out of the specula-
tive business of evaluating permanent disabil-
ity, but it would also provide that a physician,
not a judge, makes the final decision on phy-
sical impairment. □

Medical Assistants Schedule
Third Session

AAMA, Inc., State of Oklahoma, Inc., and
the University of Oklahoma presents the third
of six sessions designed to develop a first-rate
medical assistant.

The workshops are held in the Forum Build-
ing at OCCE on the University of Oklahoma
campus. Each program starts at 9:00 a.m. and
is completed by about 3:00 p.m. Continuing
Education Units at the rate of .6 CEU per ses-
sion will be earned by each participant.

Family oriented care in a physician’s office
may be given adequately by following a few
simple rules. Among these are being prepared
for emergencies, knowing more about drugs,
their side effects, and creating a clean envi-
ronment in which to treat and care for the pa-
tient. An assistant will work with ease when
she is prepared to assist the physician in physi-
cal examination of the patient, laboratory pro-
cedures, and x-ray techniques.

The third session, scheduled for December
6th, 1975, covers the clinical aspects of patient
care in the physician’s office. Gloria Peck, RN,
Instructor, Inservice Education at the New
Mercy Health Center, will be the lecturer for
this session. □

Oklahoma State Medical Association

Drug Substitution Bill Due
Reconsideration By Oklahoma
Legislature

A controversial bill designed to permit drug
substitution without the approval or knowl-
edge of the physician will apparently be recon-
sidered by the Oklahoma Legislature. David
Bickham, OSMA Associate Executive Director
in charge of legislative matters, explains al-
though physicians and pharmacists joined to-
gether to defeat the bill in May, it is eligible for
reconsideration during the 1976 session.

The controversial bill would allow pharma-
cists to substitute chemical equivalents for the
drug originally prescribed by the physician. It
has received the backing of many consumer
groups who view the bill as a means of lower-
ing health care costs, even though, in three
states where substitution statutes have been
modified, there is no evidence of any saving to
the consumer.

Representative Mark Hammons, the bill’s
sponsor, has indicated he will push hard for
favorable action by the Senate Committee on
Public and Mental Health. After a half-day

public hearing during the last session, the sub-
stitution bill was not reported out of committee.

In the last session, the OSMA’s Legislative
Committee attempted to work out a compro-
mise with Representative Hammons, and at one
time, even supported the substitution concept.
However, the committee’s safeguards were
never added to the bill, and the OSMA with-
drew its support.

Although the bill promises to save the pa-
tient money, in Canada, where substitution
has been allowed for ten years, there has been
no demonstrable savings to the patient-con-
sumer. Additionally, national surveys have
shown consumers do not want chemically-sim-
ilar drugs substituted for those prescribed,
even at a reduction in cost.

The real issue to physicians and pharmacists
is the very idea of substitution. Tests have
shown few drugs have a chemical and thera-
peutic equivalent. Also, surveys show con-
sumers are more interested in a drug’s effec-
tiveness and quality, than they are in the
price. In most cases, patients feel the physician
— not the pharmacist — should decide which
drug is used in their prescription medica-
tions. □

SPONSORED BYTHE OSMA

Washington National Insurance Company

Evanston, Illinois

offering

MAJOR MEDICAL INSURANCE
DISABILITY INCOME INSURANCE

Contact Association Counselors:

Jim Thaxton, Bill Howard or Rodman A. Frates

Administrators

720 NW 50th

PO Box 1 8593 405 842-3735 Oklahoma City 73118

Journal / November 1975 / Volume 68

437

news

Rural Health Week Slated
For Bicentennial Year

The week of April 4th, 1976, has been desig-
nated National Rural Health Week, it was an-
nounced recently by Max H. Parrott, MD, Pres-
ident of the American Medical Association.

Tennessee Ernie Ford has consented to act as
national spokesman for the week, Doctor Par-
rot said. In addition to TV and radio appear-
ances of Ford, other events are planned which
will explore in public forums the achievements
and challenges of rural health care.

The purpose of the week is to focus the atten-
tion of the American public on the health needs
of rural America, to motivate rural citizens to
become more health conscious, and to further
rural-urban cooperation in health care issues.

In addition to the AMA, the American Den-
tal Association, American Hospital Associa-
tion, American Veterinary Medical Associa-
tion, US Departments of Agriculture and
Health, Education, and Welfare, and the Na-
tional Safety Council are co-sponsors.

Other cooperating agencies and organiza-
tions include: the American Farm Bureau Fed-
eration, the National Grange, the AMA Aux-
iliary and state and local groups, the American
Agricultural Editors’ Association, the National
Association of Farm Broadcasters, the Ameri-
can Public Health Association, the American
Nurses’ Association, Inc., the American Bank-
ers Association, Prairie Farmer Magazine,
Cooperative Extension Service, Farm Founda-
tion, National Extension Homemakers Coun-
cil, and the National Rural Electric Coopera-
tive Association.

Each agency will contribute its own ex-
pertise, attacking specific segments of health
care.

The week will be action-oriented and will
center around some general topics: physician
recruitments, emergency medical services,
health education, development of health care
facilities, and community organization for de-
velopment of rural health care delivery sys-
tems.

National Rural Health Week is intended to
be an event of the Nation’s Bicentennial Cele-
bration and will coincide with the 29th Na-
tional Conference on Rural Health to be held in
Poenix, Arizona, April 7th-9th, 1976. □

438

OSMA Fills Communications Post

Don Blair, OSMA Executive Director, an-
nounced recently the appointment of Richard
L. Hess to the new position of Director of
Communications. Hess took over the OSMA
post in late October.

The new position is designed to help develop
a closer relationship between the medical as-
sociation and the public. Hess will be con-
cerned with both external and internal com-
munications. He will write and edit the OSMA
newsletter, contribute to The Journal and be in
charge of media affairs.

Hess, who holds a BA degree in political sci-
ence and a MA degree in journalism from the
University of Oklahoma, comes to the OSMA
by way of the Interstate Oil Compact Commis-
sion. He served as the IOCC’s communications
director during the past two years. His duties
there were similar to those he has assumed at
the OSMA.

When asked about the new position, Hess
said his primary goal would be to keep both the
association’s members and the public aware of
what is happening in health care. He said both
the OSMA and the medical profession have
historically done an excellent job, but the need
to tell their story still exists. He said he hopes
to open better lines of communications and let
the association’s performance stand for itself.

According to the new communications direc-
tor, "Good public relations in any field requires
two basic ingredients. First, the profession
must do a credible job, and second, it must
communicate with its public.”

Hess said with the profession’s record of ser-
vice, he can concentrate his efforts on
communications. □

Oklahomans Set For AMA Meeting

A record 310 persons have signed up for the
OSMA-sponsored trip to the American Medical
Association’s Clinical Convention in Honolulu.
A chartered 747 luxury jet will leave Okla-
homa City on November 28th and return on
December 7th, carrying probably the largest
group of Oklahomans ever to attend an AMA
meeting. While there, the Oklahoma delega-
tion will stay at the Hawaiian Regent Hotel.

The first six full days in Hawaii, November
29th through December 4th, have been set
aside for sessions of the AMA convention. The
program is designed to meet the continuing

Oklahoma State Medical Association

education needs of all physicians. Post-
graduate topics at this year’s meeting include
hyperlipidemia, pulmonary function tests,
newer antibiotics, basic and advanced EKG,
dermatology for non-dermatologists, peripher-
al vascular diseases in children, pitfalls of E.R.
x-rays, practical endocrinology, surgical le-
sions of the intestines, pediatric allergies, of-
fice gynecology, cardiopulmonary resuscita-
tion, and many others.

But, the trip won’t be all work. In addition to
an interesting special program for the ladies,
most class sessions have been scheduled be-
tween the hours of 7:15 a.m. and noon each
day, leaving the afternoons free to enjoy the
sights of Honolulu and Oahu.

As an added highlight, the OSMA tour in-
cludes a special, take your choice, trip to either
the Mauna Kea Beach Hotel on Hawaii, or the
Maui Surf Hotel on Maui Island. Participants
will spend their last two days in Hawaii on
their chosen tour before departing for Okla-
homa City on December 7th.

The ten-day and nine-night meeting-tour is
sure to provide an educational, memory-filled
experience. □

icftl Association

FREQUENCY OF ISSUE

Monthly

LOCATION OF KNOWN OF FICE OF PUBLICATION?'

2. OATE OF FILING

Sept. 29, 1975

601 N.M. Expressway, Oklahoma City,

5 LOCATION OF THE HEADQUARTERS OR GENERAL BUSINESS

and /.IP code ) I No I printer s)

tlahoma 73116

NAMES AND ADDRESSES OF PUBLISHER. EDITOR. AND MANAGING EDITOR

PUBLISHER (Name and a,

L .Med iceJ. Association, 601 N.W. Expressway. Okie. City. Okie. 73118 j

EDITOR (Name and

Mark R. Johnson. M.D.. 1219 Classen Drive. Oklahoma City, Oklahoma 73103

MANAGING EDITOR (Nar

7. OWNER (If owned by a corporation, its nam.

individual owners mutt be given. If owned by c
individual must be given.)

mount of stock. If not owned by c

NAME

Oklahoma State Medical Association 601 N.W. Expressway, Okie. City, Okie. 73HQ

KNOWN BONDHOLDERS, MORTGAGEES, ANO OTHER SECURITY HOLDERS OWNING OR HOLDING 1 PERCENT OR MORE OF
TOTAL AMOUNT OF BONDS. MORTGAGES OR OTHER SECURITIES (If there arc none, to stale)

9. FOR OPTIONAL COMPLETION BY PUBLISHERS MAILING AT THE REGULAR RATES (Section 132.121. Postal Sen. ice Ma,
39 U S. C. 3626 provide* in pertinent part "No person who would have been entitled to mail matter under former section 4359 o

y 39 U. S. C. 3626.

estfor (

e of editor, publisher, busin

(If changed, publisher mutt
submit explanation of change

11. EXTENT AND NATURE OF CIRCULATION

AVERAGE NO COPIES
EACH ISSUE DURING
PRECEDING 12 MONTHS

ACTUAL NUMBER OF COPIES OF
SINGLE ISSUE PUBLISHED NEAR-
EST TO FILING DATE

A. TOTAL NO COPIES PRINTEO (Net Press Run)

2345

2900

B. PAID CIRCULATION

1 SALES THROUGH OEALERS ANO CARRIERS. STREET
VENDORS AND COUNTER SALES

10?

2. MAIL SUBSCRIPTIONS

2U03

21*11

C. TOTAL PAID CIRCULATION

2537

2621*

O. FREE DISTRIBUTION BY MAIL. CARRIER OR OTHER MEANS
SAMPLES. COMPLIMENTARY. ANO OTHER FREE COPIES

213

228

E. TOTAL DISTRIBUTION fSum of C and D)

2805'

2352

F. COPIES NOT DISTRIBUTED

1. OFFICE USE. LEFT OVER. UNACCOUNTED. SPOILED
AFTER PRINTING

1*3

2 RETURNS FROM NEWS AGENTS

None

G. TOTAL (Sum of E A- E should vquc.i net press run shown in A)

281*5

2900

‘■h ' "■ ' '■■■■

- *.-unWr 37-

SIGNATURE OF CPTOR/PUP L
/:<

SHER BUSINESS MANAGER

DEATHS

MAUDE M. MASTERSON, MD
1911-1975

A well-known Oklahoma City
psychiatrist, Maude M. Masterson,
MD, died October 24, 1975. Born in
Walters, Oklahoma, Doctor Masterson
was graduated from the University of
Oklahoma College of Medicine in 1936
after having received her degree in
pharmacy in 1933. Doctor Masterson
had been an instructor in the Depart-
ment of Medicine at the school of her
graduation. She was a member of the
American Psychiatric Association.

RURIC N. SMITH, MD
1887-1975

A retired Tulsa ophthalmologist,
Ruric N. Snith, MD, 88, died October
23rd, 1975. A resident of Tulsa since
1920, Doctor Smith was formerly from
Atlanta, Georgia, where he worked as
a pharmacist. He graduated from the
Jefferson Medical College of Phila-
delphia in 1915. Following five years
practice in New York City, he estab-
lished his offices in Tulsa.

He was a Fellow of the American
College of Surgeons and the American
Academy of Ophthalmology and
Otolaryngology. Doctor Smith had re-
ceived both a Life Membership and a
Fifty-Year Pin from the OSMA.

WILLIAM G. PETERSON, MD
1904-1975

William G. Peterson, MD, an Ada
otolaryngologist and ophthalmologist,
died October 21st, 1975. He was a 1930
graduate of the University of Pitts-
burgh School of Medicine and had prac-
ticed his specialty for over 41 years.

Doctor Peterson was a Fellow of the
International College of Surgeons, and
was certified by the American Board of
Otolaryngology. He was a member of
the American Academy of
Otolaryngology and Ophthalmology. □

Journal / November 1975 / Volume 68

439

news

OSMA To Sponsor Pension
Program For Physicians

The association’s Board of Trustees, on
recommendation of the OSMA Council on
Insurance, has authorized the council to de-
velop a set of tax-deferred pension plans for
association members.

Self-employed physicians will be able to en-
roll in a Keogh-type program whereby they
may set aside up to $7,500 annually without
paying current income tax on that portion of
their earnings. Incorporated doctors will be of-
fered an option to enroll in either a profit-shar-
ing or a corporate-type tax-sheltered program
to be sponsored by the association. Physicians
in this group may set aside an even larger
percentage of their annual earnings.

Work on a physicians’ retirement plan began
as a result of redesigning the pension plan for
association employees. The First National
Bank and Trust Co. in Oklahoma City has
been selected as the Trustee for all investment
funds. At the present time, the investment

philosophy of the bank is being modified as a
result of significant changes in management
personnel. OSMA officials feel the investment
funds of the pension programs will realize good
earnings and sound management.

The insurance portion of the retirement
packages will be underwritten by the Massa-
chusetts Mutual Life Insurance Co. and will be
administered by the Wilson Agency in Okla-
homa City. It is one of the top agencies in
Massachusetts Mutual’s national organization,
and new personnel are being employed for the
sole purpose of handling the OSMA pension
programs. IRS-approved trust agreements are
in process now, and enrollment procedures
should be commenced by January 1st.

A survey of association members conducted
last summer revealed that 65% of the re-
spondents wanted the OSMA to enter the pen-
sion field. Many physicians, in Oklahoma and
elsewhere, have been disappointed with the
handling of their tax-deferred retirement pro-
grams. Part of the problem can be contributed
to general economic conditions, but a high per-

(Continued on Page 446)

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Therapeutic Community ap-
proach in an open setting.

Fully Accrediated
60 Beds

MEDiCENTER PSYCHIATRIC
HOSPITAL

1505 Eighth

Wichita Falls, Texas 76301

Services AvailabSe

® Psychotherapy Individual and Group

• Chemotherapy

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• Occupational Therapy

• Psychological Testing

• Psychiatric Social Worker Services

• Neurological Consultation

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• Physical Therapy

• Medical Consultations

440

Oklahoma State Medical Association

ain purpose of drug information
• the patient is to get his coopera-
n in followinga drug regimen.

eparation and distribution of
tient drug information

We would hope to amass infor-
ation from physicians, medical
sieties, the pharmaceutical indus-
' and centers of medical learning,
e ultimate responsibility for uni-
-m labeling must, however, rest
th the Food and Drug Administra-
n. There is nothing wrong with
s agency saying, “this informa-
n is generally agreed upon and
before it should be used,” as long
our process for getting the infor-
ation is sound.

Distribution of the information
a problem. In great measure it
iu Id depend on the medication in
estion. For example, in the case
an injectable long-acting proges-
one, we would think it mandatory
issue two separate leaflets— a
ort one for the patient to read be-
•e getting the first shot and a long
e to take home in order to make a
cision about continuing therapy,
this case, the information might
put directly on the package and
t removable at all. But for a medi-
tion like an antihistamine this
ormation might be issued sepa-
ely, thus giving the physician the
tion of distribution. This could
>serve the placebo use, etc.

Realistic problems must be
considered

We have to expect that the in-
troduction of an information device
will also create new problems. First,
how can we communicate complex
and sophisticated information to
people of widely divergent socio-
economic and ethnic groups? Sec-
ond, what will we say? And third,
how can we counteract the negative
attitude of many physicians toward
any outside influenceor input? Hope-
fully the medical profession will re-
spond by anticipating the problems
and helping to solve them. Assum-
ing we can also solve the difficulty
of communicating information to di-
verse groups throughout the United
States, our remaining task will be
the inclusion of appropriate material.

What information is appropriate?

In my opinion, technical, chem-
ical and such types of material
should not be included. And there is

no point in the routine listing of side
effects like nausea and vomiting
which seem to apply to practically
alt drugs, unless it is common with
the drug. Flowever, serious side ef-
fects should be listed, as should in-
formation about a medication that
is potentially risky for other reasons.

Positive aspects of patient drug
information

ly the doctor can remove that fear
20 or 30 minutes of conversation.

I’m not suggesting that we
hhold any information from the
ient because, first of all, it would
totally dishonest and secondly, it
j Id defeat the very purpose of the
art. I do think that a patient on the
:h control pill should know about
incidence of phlebothrombosis.

If you're going to tell a patient
incidence of serious adverse re-
■ ions, then you have to tell him
ta concerned medical decision
5 made to use a particular medi-
Jon in his situation after careful
isideration of the incidence of
Inplications or side effects.

otionaily unstable patients pose
>ecial problem

There are patients who, be-
se of severe emotional problems,
Ud not handle the information
itained in a patient package in-
t. Yet if we are goingto have a
kage insert at all, we just can’t
e two inserts. I think we might
ply have to tell the families of
se patients to remove the insert
n the package.

;al implications of the patient
kage insert

Just what effect would a pa-

tient package insert have on mal-
practice? We could try to avoid any
legal implications by pointing out
that the physician has selected a
particular medication because, in
his professional judgment, it is the
treatment of choice. For instance,
you can’t tell everyonetakinganti-
histamines not to work just because
a few patients develop extreme
drowsiness which can lead to acci-
dents. And what about the very small
incidence of aplastic anemia rarely
associated with chloramphenicol?

If, based on sensitivity studies and
other criteria, we decide to employ
this particular antibiotic, we do so
in full knowledge of this serious po-
tential side effect. It's not a simple
problem.

How do we handle an insert for medi-
cation used for a placebo effect?

With rare exceptions, physi-
cians no longer use medications for
a placebo effect. This question does
raise the issue of how a patient may
react to receiving a medication
without a package insert.

Preparation of the package insert

The development of the insert
ought to be a joint operation be-
tween physicians, the pharmaceuti-
cal i ndustry, the A. M. A. and the F.D. A.

Pharmaceutical

Manufacturers Association ■■■■»—

1155 Fifteenth Street, N. W. I] j j j /|9I
Washington, D.C. 20005 !■ "■#

news

(Continued from Page 440)

centage of survey respondents also indicated
dissatisfaction with their remote contact with
pension managers.

The OSMA’s Council on Insurance feels
sufficient expertise is available in this state to
successfully compete with national programs.
Physicians who choose to participate in the
OSMA pension programs will have the conven-

Miscellaneous

EXCELLENT OPPORTUNITY for general
practice in nice community near Lake Eufaula.
Privileges in modern 44-bed hospital with

446

ience of localized management and OSMA in-
volvement.

Any OSMA member who did not respond to
last summer’s survey may contact Don Blair of
the OSMA office or Bob Bell, C.L.U., at the
Wilson Agency, 1470 First National Building,
Oklahoma City, Oklahoma, 73102. Initially,
the Agency plans to contact those physicians
who previously expressed an interest in an
OSMA undertaking of this type, although all
OSMA members will be contacted on a timely
basis. □

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